How to manage a patient with COVID-19 and diabetes « Back to Blogs
Managing a patient with COVID-19 and diabetes is a delicate balancing act. It involves actively treating the infection and at the same time keeping diabetes under control.
But this is easier said than done. Some of the treatments for COVID-19 can affect diabetes. And some of the treatments for diabetes and its complications can exacerbate the systemic effects of COVID-19. This is a vitally important clinical issue. COVID-19 infection is most serious in patients with comorbidities — especially those with chronic non-communicable diseases. One of the most important and most common of these diseases is diabetes.
This all makes the paper by Singh et al on practical considerations of managing diabetes and COVID-19 vitally important. (1) The paper covers a range of different areas of overlap between both diseases — but is perhaps strongest when outlining the evidence base for different treatments.
For example, the paper gives clear guidance that certain drugs may need to be stopped because of the risk of dehydration and euglycemic ketosis and that “metformin may also need to be stopped if there is vomiting or poor oral intake”.
It also gives advice on when to start insulin and how to adjust doses. This is challenging for healthcare professionals to do for a seriously ill patient and, at the same time, ensure that they minimise the risk of transmission of infection.
At the start of the pandemic, there were concerns that variable expression ACE-2 could have adverse effects on infection with COVID-19. However, the paper reinforces current recommendations that patients who are already taking ACE inhibitors or ARBs should continue on them — unless they develop complications that necessitate their withdrawal.
Surprisingly Singh et al do not concentrate on the effects that treatment for COVID-19 might have on diabetes. For example, dexamethasone and blood glucose control or remdesivir and renal function. There is also the issue of new experimental therapies where there is little experience of their use in patients with diabetes.
These are just some of the dilemmas that healthcare professionals face when caring for a seriously ill patient with COVID-19 and diabetes. It is impossible to learn all of the different management strategies by heart. Even if it were possible, then newly published research means that the advice on all these issues changes all the time.
This is all a clear argument for clinical decision support that covers acute diseases and comorbidities and that is available all the time — so that you don’t have to remember it.
To find evidence-based and continually updated answers to these questions, look at our new BMJ Best Practice topic on COVID-19. And add diabetes.
- Singh AK, Gupta R, Ghosh A, Misra A. Diabetes in COVID-19: Prevalence, pathophysiology, prognosis and practical considerations. Diabetes Metab Syndr. 2020;14(4):303-310. doi:10.1016/j.dsx.2020.04.004
KW works for BMJ which produces the Comorbidities tool from BMJ Best Practice