Introduction:
Coronavirus disease 2019 (COVID-19), emerged in February 2020, soon spread to more than 200 nations worldwide and was deemed a global pandemic in March 2020 by the World Health Organization (WHO). With this raging third wave of COVID-19, high blood sugar level is becoming common in COVID patients under-recovery. Hence, the following clinical guidance on the diagnosis and management of diabetes among patients with COVID-19 has been established.
What Precautions Have to Be Taken in Regard to the Admission of Patients in the COVID Care Facility?
Every patient has to be screened for hyperglycemia with at least two capillary blood glucose values, one before food and one after food, by using a glucometer. And every patient with diabetes should be put on a diabetic diet. And the patient has to be monitored regularly and strictly if they adhere to the timing and quantity advised in the diet chart.
What Is a Diabetic Diet?
A diabetic diet is an eating plan which is healthy, naturally rich in nutrients, and that is low in fat and calories. It is basically eating the healthiest food in balanced amounts and sticking to regular meal times.
A good meal plan includes:
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Non-starchy vegetables such as broccoli, spinach, and green beans.
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Focus on whole foods instead of highly processed foods.
How to Screen for Hyperglycemia in Patients Admitted to a COVID Care Facility?
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Do random capillary blood glucose at the time of admission to the hospital.
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Check the capillary blood glucose before meals and after the first major meal in the hospital.
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Blood should be collected and sent to the laboratory for analysis of FPG (fasting plasma glucose) and HbA1c the following morning.
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Monitor capillary blood glucose before breakfast, before lunch, before dinner, and after dinner for at least two days to check any underlying hyperglycemia if any of the test values are high.
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Pharmacotherapy has to be initiated if any of the
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What Is the Outcome in COVID-19 Patients With High Random Blood Glucose?
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The mortality rate is found to be 24.3 percent if random blood glucose levels are more than 140 mg/dL.
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The mortality rate was greater in patients with random blood glucose greater than 140 mg/dL than in patients with random blood glucose less than 140 mg/dL and even higher in patients with known diabetes.
How to Monitor Blood Glucose for Individuals With No Evidence of Stress Hyperglycemia or Undiagnosed Diabetes at the Initial Screen?
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In case of no hyperglycemia at the time of admission and the severity of the illness increases, then re-initiate blood glucose monitoring before breakfast, before lunch, before dinner, and after dinner for at least two days which can be decreased to twice a day if values are normal. The patient is initiated on steroids.
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In the case of high-risk individuals like patients with cardiovascular disease, obesity, or patients of age above 50 years, then monitor blood glucose twice a day every three to four days.
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Patients with normal glycemic profiles at the initial phase may then develop stress hyperglycemia during the course of illness, especially if COVID severity increases.
According to a recent study, patients with COVID-19 who underwent continuous glucose monitoring had considerably larger postprandial glycemic fluctuations and exposure to hyperglycemia. Therefore, it is suggested that ongoing blood glucose monitoring should be done while the patient is receiving treatment
How to Treat Patients With Known Diabetes Who Are on Oral Antihyperglycemic Drugs (OAD)?
Patients can continue the existing oral antihyperglycemic drugs if
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The blood glucose levels are controlled (Pre-meal- <140 mg/dL: Post-meal- <180 mg/dL).
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If the patient is conscious, oriented to the environment, and has good oral acceptance.
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If the COVID symptoms are mild.
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If the kidney function test and liver function test are normal.
If the patient does not fulfill the above criteria, then the patient must be referred to an Endocrinologist to change the treatment regimen.
How to Initiate Oral Antihyperglycemic Drugs in Patients Newly Diagnosed With Diabetes?
The patient has to be consulted by an Endocrinologist or general physician. Initially, the patient can be put on tablet Metformin either immediate or sustained release 500 mg two times a day, and tablet Gliptin, provided the patient fulfills the following criteria:
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Pre-meal blood glucose is between 150 and 180 mg/dL, or post-meal blood glucose should be between 200 and 250 mg/dL.
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If the patient is conscious, oriented to the environment, and has good oral acceptance.
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If the COVID symptoms are mild.
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If the kidney function test and liver function test are normal.
When to Use Oral Glucose-Lowering Agents?
Patients can be prescribed oral glucose-lowering agents when:
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There are no contraindications for oral glucose-lowering agents.
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The symptoms of COVID are mild.
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Mild hyperglycemia:
Pre-meal < 180 mg/dL
Post-meal < 250 mg/dL.
Which Are the Safer Oral Glucose-Lowering Drugs?
The safe drugs are:
1) Vildagliptin or Teneligliptin.
2) Sitagliptin or Linagliptin.
Which Are the Drugs That Should Be Given With Caution?
The drugs that should be given with caution are listed below.
- Metformin- As there is a risk of lactic acidosis if the patient is moderate to severely ill with hypoxia (low oxygen level).
- Sulfonylureas- As there is a risk of hypoglycemia if there is poor oral intake or with concomitant use of insulin therapy.
And these drugs need to be stopped if the severity of the disease increases and should not be initiated in patients who are not on these drugs.
- SGLT-2 Inhibitors (sodium-glucose co-transporter 2 inhibitors) - It can increase the risk of dehydration.
- Pioglitazone- It increases the risk of fluid retention and edema (inflammation). It is contraindicated in patients with cardiac or hepatic dysfunction.
How to Initiate Insulin for Patients Newly Detected With Diabetes?
Insulin can be given in patients with the following blood glucose levels:
- Before food- Blood glucose > 180 mg/dL
- After food- Blood glucose > 250 mg/dL.
The total daily dose that can be given in patients above the age of 65 years and with nephropathy or any other liver disease is 0.2 units/kg/day. The total daily dose should be divided into four doses:
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Three doses are given as bolus insulin - Regular Insulin is given 30 minutes before breakfast, before lunch, and before dinner.
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One dose for basal insulin - Injection NPH (neutral protamine Hagedorn) insulin that has to be given at bedtime about two hours after dinner.
How to Give Insulin for Patients on Oral Antihyperglycemic Drugs and Still the Blood Glucose Levels Are Not Under Control?
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When the pre-meal blood glucose value is in the range between 140 to 180 mg/dL or if the post-meal blood glucose values are between 180 mg/dL to 250 mg/dL, then the patient has to be referred to an endocrinologist for optimizing the oral antihyperglycemic drugs.
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If in case the pre-meal blood glucose values are more than 180 mg/dL in spite of being on oral antihyperglycemic drugs, then the patient should be started on basal-bolus insulin treatment.
Injection of regular Insulin is not required to be given for all three meals but can be added to any individual meal that requires prandial coverage.
How to Decide the Initial Doses of Insulin for Steroid Induced Worsening of Blood Glucose in People With or Without Diabetes?
Conclusion:
Studies show that compared to patients with normoglycemia, people with diabetes and an uncontrolled hyperglycemic condition had a 54 percent higher risk of complications including death while being treated in a hospital for COVID-19. Therefore, in patients with diabetes, preventing a COVID-19 infection in the first place is the most preferred to avoid complications. Diabetic patients should take vaccinations to keep their immune levels high to fight against the virus. Vaccines are absolutely safe and effective.There is no evidence that the COVID-19 vaccine has a negative effect on glycemic control. Also, following adequate precautionary guidelines is essential. When experiencing symptoms, reaching out to a healthcare provider at the earliest is needed to prevent the disease progression and further associated complications.
