key: cord-0711615-9ebw3x8r
authors: Gupta, Ritesh; Misra, Anoop
title: Clinical considerations in patients with diabetes during times of COVID19: An update on lifestyle factors and antihyperglycemic drugs with focus on India
date: 2020-09-08
journal: Diabetes Metab Syndr
DOI: 10.1016/j.dsx.2020.09.009
sha: f06b4f067ac09bbba854ce4e91a5d911a51a2182
doc_id: 711615
cord_uid: 9ebw3x8r

BACKGROUND: Diabetes is recognized as an important comorbidity in patients with COVID-19 and a large amount of literature has become available regarding this. The aim of this article is to review the literature regarding various aspects of association between diabetes and COVID-19 and to highlight clinically relevant points with focus on India. METHODS: We searched Pubmed and Google Scholar databases for articles regarding diabetes and COVID-19 published between March 19, 2020 and August 30, 2020. RESULTS: Diabetes and poor glycemic control are associated with increased severity and mortality in patients with COVID-19. Several clinical scenarios about hyperglycemia and COVID-19 are identified and each of these needs specific management strategies. CONCLUSION: It is prudent to maintain good glycemic control in patients with diabetes in order to minimize the complications of COVID-19. There is a need for well conducted studies to asses the role of individual antihyperglycemic therapies in COVID-19 and also the behavior of new onset diabetes diagnosed either after COVID-19 infection or during this time.

We searched Pubmed and Google Scholar databases for articles regarding diabetes and COVID-19 published between 19th March 2020 and 30th August 2020.

Diabetes and poor glycemic control are associated with increased severity and mortality in patients with COVID- 19 . Several clinical scenarios about hyperglycemia and COVID-19 are identified and each of these needs specific management strategies.

It is prudent to maintain good glycemic control in patients with diabetes in order to minimize the complications of COVID-19. There is a need for well conducted studies to asses the role of individual antihyperglycemic therapies in COVID-19 and also the behavior of new onset diabetes diagnosed either after COVID-19 infection or during this time.

After the first reported case of COVID-19 in China in December 2019, the pandemic has rapidly spread worldwide. The association of diabetes and COVID-19 was identified initially and clinical considerations about the same were published by us in a highly cited article, one of the first on this subject, in March 2020 1 . Present article is an update of the previous article since J o u r n a l P r e -p r o o f much information has become available about the relationship between diabetes and COVID-19 since then, with focus on India.

We searched Pubmed and Google Scholar for articles regarding diabetes and COVID-19 published between 19 th March 2020 and 30 th August 2020. In this article, we present pertinent points relating to clinical aspects and new evidence which has emerged during this period. c. Effect of glycemic control on disease course and severity: There is evidence that good glycemic control could reduce the severity of COVID-19.Well controlled diabetes was associated with significantly lower mortality compared to individuals with poorly controlled diabetes (adjusted HR, 0.14; 95% CI, 0.03-0.60; p = 0.008) 5 in a recent study. Information about diabetes in COVID-19 in Indian patients is sparse at present. In a study in 522 patients hospitalized with COVID-19 till 20 th April 2020 in Jaipur, Western India, diabetes was present in 5.5% of patients 12 . Another study in patients from Rajasthan reported a prevalence of diabetes to be 4.7% in 234 patients with COVID-19 13 . Clearly, further studies are needed to ascertain this limited data.

The imposition of lockdown and restrictive measures in many regions to contain the pandemic has posed challenges in access to healthcare, supply of medicines and insulin 14 . Moreover, dietary irregularities, reduced exercise, and mental stress have led to weight gain as seen in a questionnaire-based study by in 150 patients with type 2 diabetes as shown by us 15 . In a study in 143 patients with diabetes in Central India, 39% patients reported worsening of hyperglycemia 16 .

A small study on 52 patients with type 1 diabetes in north India showed a statistically significant increase in average blood glucose and HbA1c during lockdown 17 . This is in contrast to the findings of improved glycemic control and reduced glycemic variability in studies in type 1 diabetes done in Spain, Italy and United Kingdom 18, 19, 20 .

Restrictions during lockdown could also be an important contributing factor in development of diabetes in predisposed individuals. In a study in 100 people without diabetes, weight gain was reported by 40% respondents and this led to about 7% increase in number of people with high ADA diabetes risk score 21 . This is especially important for South Asians who have a higher risk of conversion from prediabetes to diabetes PMID: 30287102. Not only does this finding have an implication for future burden of diabetes and its complications, it could also lead to increased morbidity because of COVID-19.

As the understanding of infection with SARS CoV2 has evolved, two factors have come to be Table 1 shows the studies examining the effect of metformin on mortality due to COVID-19. The largest study showed that metformin use for at least 90 days in the preceding 12 months was significantly associated with reduced mortality in hospitalized patients with COVID-19; however this benefit was observed in women only. This could be attributed to the preferentially greater anti-inflammatory effect (preferential effect on interleukin-6) of metformin in women 37 .

Considerations about the use of other anti-diabetic agents remain the same as in any acute infection 23 However, good glycemic control is prudent while using steroids. Also indiscriminate use in mild disease is detrimental and is strongly discouraged.

Telemedicine has proved to be useful in providing consultation and education to patients in times of restricted social mobility and continues to be utilized in view of the need to minimize direct contact of patients with hospital/healthcare facility 28, 29 . However, there are challenges and limitations of telemedicine especially in developing countries. These include poor internet connectivity, poor digital literacy, hearing problems, among others 30 .

Apart from the usual preventive measures like social distancing and use of masks, good glycemic control needs to be emphasized in order to minimize severity of COVID-19. There is no chemoprophylaxis recommended in patients with diabetes. Benefit of nutritional supplements like vitamin C, zinc, selenium, vitamin A and vitamin D etc. has been seen in vitro, however clinical evidence is not sufficient to recommend their supplementation 31 . Vitamin D deficiency has been shown to be correlated to mortality in COVID19, however benefit of intervention has not been demonstrated 32 . It is reasonable to advise a healthy balanced diet with increased servings of protein, fruits, vegetables and nuts 33 .

In light of the evidence about role of diabetes and hyperglycemia in determining the severity of COVID-19, and the effect of the disease and lockdown on the glycemic status of people with and without diabetes, it is becoming increasingly important to recognize the different scenarios where diabetes and COVID-19 interact. A recent article by a consortium of diabetes experts in J o u r n a l P r e -p r o o f India has identified five categories of patients with hyperglycemia who need consideration in today's times of COVID-19 pandemic 34 . Each of these need appropriate management as given in Table 2 .

Mortality due to COVID-19 is high even in those individuals not known to have diabetes. With a large pool of undiagnosed people with diabetes in India, it is reasonable to recommend a blood glucose check in Asian Indians above 30 years who have COVID-19. 

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The authors declare no conflict of interest with reference to the manuscript titled "Clinical considerations in patients with diabetes during times of COVID19: an update on lifestyle factors and antihyperglycemic drugs with focus on India".

Anoop Misra J o u r n a l P r e -p r o o f