COMMENTARY

The Latest on Post-COVID Recovery in Diabetes Care

Prof Kamlesh Khunti 

Disclosures

October 04, 2021

This transcript has been edited for clarity.

Hello, my name is Kamlesh Khunti, I'm professor of primary care, diabetes, and vascular medicine at the University of Leicester.

Thank you for joining me today. And I'm just going to give you highlights of the presentation I've just done at the European Association for the Study of Diabetes (EASD) 2021 Annual Meeting – virtually. 

Post COVID

It was regarding care of people with diabetes post COVID-19 in primary care. We know that people with diabetes have been disproportionately affected because of COVID. In a meta-analysis that we conducted early on in the pandemic, we found about 12% of people had diabetes, some studies have found 20%/25% of people with COVID have diabetes. But we also found a number of people have other chronic conditions that are associated with diabetes, such as hypertension, and cardiovascular disease. We also found that people with these conditions were at risk of severe COVID-19 – and severe COVID meaning hospitalisation or a mortality. For example, hypertension was associated with a 66% risk of severe COVID; diabetes a 2-fold increase association, CKD [chronic kidney disease] with nearly 4-fold increase association with severe COVID. So severe COVID seems to be affecting people with cardiometabolic conditions.

Disaster Impact

And we also talk about natural disasters. Well, we're certainly in a natural disaster now. Something that we have not faced in our lifetime.

During natural disasters you get a number of interruptions, and natural disasters are things such as earthquakes, cyclones, extreme temperatures, hurricanes and tsunamis. And you get effects at the individual level, because of the supply, how people with diabetes will feel, and also the institutional disruption to public health infrastructure. So, getting access to healthcare professionals, getting access to certain types of food. And all of these will have an impact on the person with diabetes in terms of glycaemic control, blood pressure, impaired glucose tolerance, and the mental health impact. And this will exacerbate their condition.

We've already got data from hurricane Katrina and tsunamis that even within a short term, we get increased risk factors, such as increased HbA1c, people are on more insulin, and increased blood pressure, lipids, and suddenly increased [people with] poor quality of life.

Pandemic Consequences

In terms of the pandemic, we've seen that diabetes is the most affected condition that healthcare providers have suggested in a global survey, and hypertension and diabetes being the two comorbid conditions that have had the most impact due to the COVID-19 reductions.

And in terms of COVID-19, during the pandemic, diabetes services have been interrupted for the patients. So people with diabetes have been shielding, isolating because they're clinically vulnerable, there's been social distancing measures, the suspension of routine appointments, and redeployment of healthcare staff. And so this will have both direct and indirect consequences for that person with diabetes.

We've already seen data presented at the EASD and published that there's been a reduction in new diagnoses of diabetes by about 70% compared with previous years.  HbA1c testing monitoring in people with diabetes has been reduced by 77% to 84%. And care processes - this is how often we measure people's retinopathy, feet, check blood pressure, HbA1c check, lipid check, that's been reduced from about 58% to around 20%.

Open Up

So all of this is a backlog of patients that we will now need to manage, in primary care particularly. And we know from previous studies, that even short-term delays are associated with worse outcomes. So for example, a one year delay in getting HbA1c down below 7% is associated with increased risk of myocardial infarction, heart failure, stroke, and composite cardiovascular events. There's also other data showing that it’s associated with increased nephropathy, neuropathy, and retinopathy.

So short-term delays we've seen in the other natural disasters. With COVID we've had 18 months of delays. So how do we get around this in terms of managing these people? Well, I think we need to start opening up now. And in the recovery phase, we need to identify people who are at the highest risk and call them in earlier. And the lowest risk may be a little bit later down. And a number of risk stratification tools have been developed, for example, the Primary Care Diabetes Society have developed one where they've highlighted red, amber or green. Red, we would see them within 3 months, amber within 6 months and green within 12 months. And in terms of the risks categories, you're all aware, it's based on high blood pressure, number of complications they have, having CKD, cardiovascular disease, heart disease or stroke, and high BMIs. But lots of patients will have ambers as well. So two or three ambers would put them in the red category that would need to see them urgently.

We mustn't forget the impact that the pandemic has had on the mental health of people with diabetes. And really, we need to be referring patients for self-management education programmes. And here, they don't need face-to-face consultations, there are a number of self-management programmes that are available online and for people to access remotely. Even when you need face- to-face, they can be done by a video assessment as well.

Readmission

Other areas we need to consider as we come out [of the pandemic] is this area of new onset diabetes that may be associated with COVID-19. We don't know whether this is a true association or not, because it could be due to stress hyperglycaemia, we've seen in heart attacks for example; it could have been pre-existing diabetes that wasn't picked up until the person with diabetes was admitted; it could be due to in-hospital steroid-induced diabetes, or it could be due to the novel concept of SARS-CoV-2 binding on the H2 receptors in the pancreatic islets and beta cells and destroying them. Now, all of these are speculations and what we need is further research, especially following these patients up when they're discharged from hospital.

We know from some studies that we and others have done that the number of people who are readmitted is increased following discharge from hospital with COVID. So normally, we've seen that around 10% to 30% of people die in hospital. But even those who survive hospital admission and the discharge, about 12% will die within 140 days and around 30% will be readmitted within 140 days. And when you look at the readmission rates in these studies, they show that people are readmitted more likely to be with diabetes, heart attacks, heart failure, chronic kidney disease, chronic liver disease, and these are much, much, higher, significantly higher compared with the control groups they use which were pre-pandemic.

Recovery Phase

So lots of things to consider as we go into the recovery phase. The kinds of things we need to start thinking about is inpatient care needs to be continuous. There are still beds blocked by people with COVID and we need to ensure that people with diabetes do get access to these. We need to continue the outpatient, urgent, acute diabetes care, routine care we need to start especially in primary care. We've seen foot services disrupted and foot care is not something that we can do by remote consultations, we really need to start seeing these people with foot diseases. Pregnancy services, we know women who are pregnant have been, again, highly affected with COVID-19. We need to start doing blood tests on these patients. There's been 18-month delays for some patients. We need to bring them in, look at their risk factors and assess and treat appropriately. Retinopathy we haven't got a huge amount of data on retinopathy and the delays and what that may lead to in the future. And finally, we need to start following the nuance of people with diabetes and see if this is truly new onset, and also long COVID, which we haven't talked about today, but we've seen more and more people with long COVID and we need to follow these people up and made sure that we're managing them appropriately.

Finally, what we really need to do is ensure that everyone with diabetes and their carers get COVID vaccinations, because that's the way we're going to get out of this pandemic. In terms of looking at people with diabetes and immunisation with COVID vaccines, new data have recently come out, showing that people who have poor glycaemic control, then the vaccination induces much lower and weaker immune response. It's so essential that we do get glycaemic control right, even prior to people getting the vaccine. Thank you very much for joining me.

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