Anne L. Peters, MD, is one of our favorite docs in diabetes and with good reason. She’s smart, translates science into ordinary speak and makes us feel seen and safer relating to everyone with diabetes on a human level. Dr. Peters is a professor of medicine at the University of Southern California (USC) Keck School of Medicine, Director of the USC clinical diabetes programs, author of more than 200 articles, reviews, and abstracts and three books, and has been an investigator for more than 40 research studies.
From Dr. Peters:
The data that we have suggest that people with diabetes are actually not at increased risk for catching the novel coronavirus, but once they become infected, they may do less well, particularly if they’re in an ICU setting.
However, we don’t know if there are any differences between people with type 1 versus type 2 diabetes, or between people whose diabetes is well controlled versus less well controlled. We do know that younger people as a whole do better than older people. The more comorbidities present, such as cardiovascular disease and chronic kidney disease, the higher the risk for mortality and doing poorly.
Historically, we’ve believed that people with higher glucose levels are likely to be at greater risk for infection than those with more normal glucose levels. This is because high glucose levels can inhibit white cell function. We obviously want our patients to be as well controlled as possible in order to help them do better.
Some Patterns Emerge
I have now seen patients with diabetes who have been infected with COVID-19 and heard cases of many others. No one in my personal practice with type 1 diabetes has developed COVID-19, but I have seen a number of people with type 2 diabetes who have had it.
What I know for sure is that I can’t predict this virus. I have had people with every known risk factor for a poor outcome do incredibly well, and those with fewer risk factors do worse than I expected. I’ve seen families in whom everybody was infected, and families where only one member became ill.
However, some patterns have emerged. Unscientifically, I divide my patients into three groups of illness severity: mild, moderate, and severe. Mild is when COVID-19 is a slightly annoying head cold and nothing more. Moderate is where people feel miserable; they’re feverish, they have muscle pain, they have headaches, their lungs hurt, they cough, and they feel wretched—but they don’t need to be in the hospital and they survive. Then there are the severe cases; these patients are hospitalized, and some of them end up in the ICU.
In terms of diabetes management, it’s the moderate category where we really have to do our most aggressive outpatient care. We don’t want these patients to end up in the hospital. The biggest issue I deal with is dehydration. My patients are febrile and they’re often anorexic, not wanting to eat or drink much, so I really have to encourage hydration.
I’ve also seen patients with glucose levels lower than normal, which is different from what I’m used to seeing in patients with infection. Glucose monitoring is incredibly important in patients with COVID-19.
Changes to Medications
My first step in all patients who are on an SGLT2 inhibitor is to stop the drug at the first sign of symptoms. I’ve had a lean person with type 2 diabetes on an SGLT2 inhibitor go into diabetic ketoacidosis (DKA) when they developed COVID-19, so this is very important. This patient had already stopped their SGLT2 inhibitor for a day when they became quite ill.
Other practitioners, such as my dear friend, Dr Irl Hirsch, suggest that we stop SGLT2 inhibitor therapy in all people with type 1 diabetes who are using them off-label because it increases the risk for DKA. I haven’t done that in my patients except for those who I feel are on too low a dose of insulin or who seem to be at higher risk for DKA than others. For my patients who are able to test for ketones and connect with me, I’ve kept them on their SGLT2 inhibitor, but I suggest monitoring this on a case-by-case basis.
In my patients with type 1 diabetes, I make sure that they are prepared with glucose-containing fluids at home, and that they’re able to give injected insulin. I also make sure that they have ketone test strips at home and some sort of antiemetic so they can keep down fluids.
Preparing a Hospital Kit
There has been an issue in hospitals where patients on insulin drips can’t get hourly blood glucose readings because the staff doesn’t have enough personal protective equipment to go in and out of patient rooms to do the testing. Patients must be prepared to do self-monitoring of glucose levels in the hospital if they happen to end up hospitalized. I encourage patients with type 1 diabetes and those with type 2 diabetes on insulin to prepare a kit that they could bring with them to the hospital. This kit includes testing supplies (if people are doing self-monitoring of blood glucose) and sensors (if people are on a sensor).
People need to remember such details as bringing charger cables for their iPhones, iPads, and anything else they may need to help self-monitor their glucose levels if hospitalized. This is particularly important now because family members aren’t allowed into hospitals to bring the pieces that someone may have forgotten at home.
In people with type 2 diabetes who are on insulin secretagogues and/or insulin, I have needed to lower the dose of medication, and in some cases, to stop it. Again, self-monitoring is important.
As patients recover from their COVID-19 infections, they may still not feel much like eating and have relative anorexia. There have been some cases where I have held the GLP-1 receptor agonist therapy for a week or two after the illness has resolved to make sure my patients return to their fully normal baseline state.
The most important advice I give patients is to reach out to us, their healthcare team, if they need us. None of us want anyone to go to the hospital, but there are patients who develop DKA and can’t keep down fluids, and they need to be hospitalized. Patients shouldn’t wait, because the DKA may become even more severe by the time they’re admitted.
We all need to keep in mind that most people are going to be okay, with or without diabetes—although, tragically, some will die. As a healthcare provider, I am encouraging my patients to use this time to take extra good care of themselves, to learn to optimize their diabetes control when not being distracted by going out to social events, dinner, or work.
I think we are helping our patients establish a new baseline that will hopefully translate into sustained health over time. Please be sure to take care of yourselves, your families, and your patients. Be well.