key: cord-0718504-pst36zcg
authors: Pathan, Faruque; Selim, Shahjada; Fariduddin, Md; Rahman, Md Hafizur; Ashrafuzzaman, S M; Afsana, Faria; Qureshi, Nazmul Kabir; Hossain, Tanjina; Saifuddin, M; Kamrul-Hasan, A B; Mir, Ahmed Salam
title: Bangladesh Endocrine Society (BES) Position Statement for Management of Diabetes and Other Endocrine Diseases in Patients with COVID-19
date: 2021-05-18
journal: Diabetes Metab Syndr Obes
DOI: 10.2147/dmso.s293688
sha: 2711a561aa92536ef30a37f10d6b9aef0239f1bd
doc_id: 718504
cord_uid: pst36zcg

BACKGROUND: The year 2020 witnessed a largely unprecedented pandemic of coronavirus disease (COVID-19), caused by SARS COV-2. Many people with COVID-19 have comorbidities, including diabetes, hypertension and cardiovascular diseases, which are significantly associated with worse outcomes. Moreover, COVID-19 itself is allied with deteriorating hyperglycemia. Therefore, Bangladesh Endocrine Society has formulated some practical recommendations for management of diabetes and other endocrine diseases in patients with COVID-19 for use in both primary and specialist care settings. OBJECTIVE: The objective of the article is to develop a guideline to protect the vulnerable group with utmost preference – the elderly and those with comorbid conditions. Therefore, to ensure the adequate protective measures and timely treatment for COVID-19 patients with diabetes, other endocrine diseases or any other comorbidities. CONSIDERING AND MONITORING ISSUES: The risk of a fatal outcome from COVID-19 may be up to 50% higher in patients with diabetes than in non-diabetics. Patients with diabetes and COVID had CFR 7.3–9.2%, compared with 0.9–1.4% in patients without comorbidities. Diabetic ketoacidosis may be one of the causes of mortality in COVID-19. There is wide fluctuation of blood glucose in these patients, probably due to irregular diet, reduced exercise, increased glucocorticoids secretion, and use of glucocorticoids. HbA1c should be <7.0% for the majority of the patients, this target may be relaxed in appropriate clinical settings. More emphasis should be given on day-to-day blood glucose levels. Hypoglycemia (<3.9 mmol/l) must be avoided. Frequent monitoring of blood glucose is needed in critically ill patients. CONCLUSION: The fight against COVID-19 has been proven to be a challenging one. Therefore, all healthcare personnel should make the best use of updated knowledge and skills to ensure adequate protective measures and timely treatment for COVID-19 patients with diabetes, other endocrine diseases or any other comorbidities.

The year 2020 witnessed a largely unprecedented pandemic of coronavirus disease , caused by SARS COV-2. Many people with COVID-19 have comorbidities, including diabetes, hypertension and cardiovascular diseases, which are significantly associated with worse outcomes. 1 Moreover, COVID-19 itself is associated with worsening of hyperglycemia. Depending on the global region, 20-59% patients in the COVID-19 pandemic had diabetes. 2 In Bangladesh, one in every 12 adults has diabetes, with a prevalence of 8.4%. 3 Data suggest that only 22.5% of patients with diabetes have good glycemic control. 3 Therefore, the Bangladesh Endocrine Society has formulated some practical recommendations for management of diabetes and other endocrine diseases in patients with COVID-19 for use in both primary and specialist care settings.

The risk of a fatal outcome from COVID-19 may be up to 178-221% higher in patients with diabetes than in nondiabetics. [4] [5] [6] Data show that patients with diabetes and COVID had CFR 7.3-9.2%, compared with 0.9-1.4% in patients without comorbidities. 7, 8 Diabetic ketoacidosis may be one of the causes of mortality in COVID- 19. 9 There is wide fluctuation of blood glucose in these patients, probably due to irregular diet, reduced exercise, increased glucocorticoids secretion, use of glucocorticoids etc. Also, COVID-19 can induce a large number of inflammatory cytokines leading to severe insulin resistance. 10 The reason behind increased severity of COVID-19 in diabetes is complex. Gupta et al. noted that poor glycemic control impairs several aspects of the immune response to viral infections.

Inappropriate T-cell action, impaired NK cell activity and defects in complement action can reduce viral clearance. Diabetes and obesity are associated with abnormal secretion of adipokines and cytokines such as TNF-α and interferon, predisposing to severe infection. Plasminogen is increased in diabetes, increasing the virulence of SARS CoV-2. 11 Higher levels of IL-6, ESR, CRP, ferritin, fibrinogen and D-dimer were reported in patients with diabetes compared with nondiabetics. 12 Furin, a membrane bound protease involved in the entry of coronaviruses into the cell, is increased in diabetes, which may promote viral replication. Comorbidities such as hypertension, CAD and CKD further worsen the prognosis. 11 Figure 1 shows a summary of postulated mechanisms of increased severity of COVID-19 in diabetic patients.

Angiotensin-converting-enzyme 2 (ACE2) has been identified as the receptor for the coronavirus spike protein. COVID-19 infection decreases ACE2 expression, increasing the risk of cellular damage, hyperinflammation and respiratory failure. 13 Chronic hyperglycemia downregulates ACE2 expression making the cells vulnerable to the inflammatory effect of the virus. But acute hyperglycemia upregulates ACE2 expression, facilitating viral cell entry. It is also postulated that COVID-19 can induce new onset diabetes via its direct effect on pancreatic β cells which express ACE2 receptors. [14] [15] [16] Glycemic Targets and Glucose Monitoring HbA1c should be <7.0% for the majority of the patients, this target may be relaxed in appropriate clinical settings. 17 More emphasis should be given on day-to-day blood glucose levels. Hypoglycemia (<3.9 mmol/l) must be avoided (Table 1) . 17, 18 In the case of continuous glucose monitoring/flash glucose monitoring, time-in-range (3.9-10.0 mmol/l, 70-180 mg/dL) should be >70% of the time (or >50% in frail and older people and moderate to severe cases). 2 For severe and critically ill patients who are on intravenous insulin infusion, the glycemic target should be 7.8-10 mmol/L (140-180 mg/dL). 

Self-monitoring of blood glucose (SMBG) is an acceptable alternative to laboratory plasma glucose estimation in the present scenario. SMBG should be checked at any clinical suspicion of hypoglycemia. [19] [20] [21] Frequent monitoring of blood glucose (every hour or every 2 h) is needed in patients with very poor oral intake or those in ICU or non-ICU who are on mechanical ventilation who would require intravenous insulin infusion. [19] [20] [21] Table 2 shows the recommended frequency of SMBG in COVID patients.

Continuous glucose monitoring (CGM) may confer additional benefit in terms of glycemic control in patients receiving multiple dose insulin injections, continuous subcutaneous insulin infusion (CSII) or insulin pump or intravenous insulin syringe pump. [19] [20] [21] [22] Nutrition Management and Physical Activity in COVID-19 and Diabetes Some conditions may interfere with a healthy regular diet, such as anorexia and anosmia, gastrointestinal symptoms such as diarrhea, vomiting, dehydration, irregular schedule, lack of care in isolation ward, stress, anxiety, insomnia etc. 23 During sick days, the patient should follow the regular calorie and schedule given before. To maintain hydration at least half a cup (100 mL) of water or unsweetened drinks should be taken hourly. The patient should not miss meals and should not fast. If unable to eat much, he/she should try snacks or drinks with carbohydrates.

A regular meal schedule should be maintained. Glucose 

drink or lozenge or tablet should be kept with the patient in their isolation room or ward. Plenty of fruits and vegetables, at least 2 or 3 servings a day, should be taken. If the patient is unable to eat due to vomiting or cannot remain hydrated, then urgent medical help is needed. 24, 25 Enough lean protein such as fish, meat, egg, milk, cheese, seeds or nuts should be consumed. Protein restrictions (0.8 g per kg body weight) may be needed in chronic kidney disease with diabetes. 26 In critical, intubated or ventilated ICU patients with COVID-19, enteral nutrition (EN) should be started through a nasogastric tube. Isocaloric nutrition rather than hypocaloric nutrition can be increasingly implemented after the early stage of acute illness. Blood glucose should be continued at target levels with monitoring of blood triglycerides and electrolytes including phosphate, potassium and magnesium. 26 There are recommendations for the population to take vitamin D supplements during this pandemic. 27 Zinc has been shown to have inhibitory effects on H 1 N 1 viral load, but any effect in COVID-19 is unknown. 28 Vitamin C supplementation has some role in prevention of pneumonia and its effect in COVID-19 needs evaluation. 29 During sick days, vigorous exercise is not advised. If the disease category is mild some home exercises can be done. Breathing exercises and maintaining a prone position is beneficial. The patient should walk for a few steps or move their legs every 2 hours to prevent thromboembolism. Specialist respiratory physiotherapists may be needed in hospitals and ICU setting. Enough sleep is necessary. [30] [31] [32] Home Management, Indications for Hospital Care and Sick Day Rules

At home, the patient should remain isolated in a single room, use a single toilet, should practice hand washing with soap-water 20 seconds each time frequently or before/after taking meal or after using washroom, after coughing, sneezing. A 60% alcohol-based sanitizer can be used. Cough/sneezing etiquette can be maintained by using tissue paper, cloth or elbow/hand. Face mask should be used. Care should be given by a single healthy person maintaining protective measures. Home floor, furniture, door knobs, light switch, sink, toilet seat, handles should be cleaned and disinfected after use. Meditation, prayer can help in minimizing stress and anxiety. News that can cause distress or anxiety should be minimized. Regular sleep is essential. Contact with relatives, friends and neighbors via telephone, online communication can be practiced to reduce effects of social isolation. Supply/storage of prescribed anti-diabetic medications/refills at home should be ensured for one to three months. 33-36 Table 3 shows the proposed indications of hospitalization in diabetic patients with COVID-19.

People with DM should stay at home as much as possible to reduce exposure risk. If it is necessary to go out, crowds should be avoided, social distancing should be maintained by 1-2 meters and a face mask should be used. Routine clinic visits can be minimized while telemedicine/ video consultations, telephone advice, online drug delivery • Four times/day and should include preprandial, post-prandial and bedtime levels.

• In well-controlled diabetes, daily fasting and after the major meal may be justified.

• Fasting and post-prandial capillary blood glucose once or twice a week.

• At least 4 times/day and should include preprandial, post-prandial and bedtime levels. Note: Data from Banerjee et al, 19 Basu et al, 20 

Metformin is the widely used first-line antidiabetic agent for management of type 2 diabetes mellitus. It is responsible for the activation of the AMP-activated protein kinase (AMPK) in the liver and thereby decreases hepatic glucose output. 38 The activation of AMPK by metformin also leads to phosphorylation of ACE2 which can lead to conformational and functional changes to this receptor. 39 Activation of ACE2 increases its protective anti-inflammatory activity which may prevent hyperinflammation in COVID-19 infection. 40 Metformin also has anticipated antiproliferative and immunomodulatory effects due to activation of AMPK and has shown to have a protective role in pneumonia in mouse model and decreased mortality in sepsis, tuberculosis and COPD in previous human studies. 41 Meanwhile, several studies have reported the outcomes of metformin use in patients with type 2 diabetes with COVID-19. Although one study reported an increase in severity of infection with metformin use, some studies found neither harm nor benefit both in severity and mortality, but the majority reported a significant reduction in mortality. 42 Metformin also has an indirect effect to decrease replication of this virus. 43 Considering all these, although there are no recent good data in COVID-19, metformin may be a real game changer in COVID-19 pandemic. 40 It is evident that lactic acidosis • Blood glucose >15 mmol/l (>270 mg/dL) on repeated measurements.

• Ketones in urine.

• Excessive thirst.

• Vomiting or diarrhea persist for more than 6 hours.

• Unable to take food and drinks for 6 hours.

• Weight loss of ≥2.5 kg during the illness.

• Rapid breathing.

• Abdominal pain.

• Reduced level of consciousness (drowsiness).

• Co-existing serious morbidities.

• 46 Recently, it has been hypothesized that SGLT-2i, GLP-1RAs and pioglitazone might induce an over-expression of the ACE2 receptor, which may have more serious consequences if a diabetic patient is infected. 47, 48 GLP-1RA has shown over the years a significant anti-inflammatory and anti-adipogenic effect. 49 Similar evidence of anti-inflammatory effect is also seen with SGLT-2i and pioglitazone. 50, 51 Although there is increased chance of COVID-19 infection through ACE2 overexpression, pioglitazone also reduces proinflammatory cytokines and inflammatory markers, and cytokine storm and fibrotic lung damage. 41 The usefulness of both GLP-1Ra and SGLT-2i for the prevention of cardiovascular and kidney disease is well known. With COVID-19, people with the presence of a cardiovascular or kidney disease show a worse prognosis. 52,53 Therefore, it seems to be mandatory to preserve the integrity of kidney and of the cardiovascular system in people who could be affected by SARS-CoV-2. 48 Also euglycemic or moderate hyperglycemic DKA with SGLT-2i are rare events and predictable only in severe or critical COVID 19 illness and especially in a background of poor food intake, dehydration and hypovolemia. 2, 41 Insulin is the most potent, appropriate and safest antidiabetic agent in any acute infection. Although there are claims and counter claims regarding ACE2 overexpression with insulin in COVID-19, multiple stresses including respiratory failure and sepsis in severe COVID-19 infection lead to defects in insulin secretion and action. So, most patients will require insulin in high dose during this infection. 2 Tables 4 and 5 summarize the recommendations for use of anti-diabetic agents and drugs used for other comorbidities in diabetic patients with COVID-19. Table 6 summarizes the recommendations for management of diabetes according to severity.

Follow BES Insulin Guideline for insulin initiation and intensification (section 3). 56 Regarding use of investigational anti-COVID-19 drugs (e.g., hydroxychloroquine), consider their glycemic effects. 10 

COVID-19 disease is a challenge for diabetic patients. Presence of diabetes increases disease severity and mortality in COVID-19 patients. Glycemic control needs to be optimal during this pandemic situation. Diabetes management in hospital setup both in outpatient department (OPD) and inpatient needs attention. Access of diabetes patients to outpatient clinics is limited during this pandemic and this urges alternative treatment options, particularly the implementation of telemedicine services. In spite of this situation there will be a few required OPD visits and these can be prioritized as follows. 2 Singh and Khunti, 41 Singh et al, 42 Ceriello, 51 Royal Australian College of General Practitioners, 54 

Intravenous insulin is rational for most general surgical and medical patients outside the ICU. Insulin analogues usually produce a lower incidence of hypoglycaemia than do regular human or Neutral Protamine Hagedorn (NPH) insulin. This is preferred treatment for non-critically ill hospitalized patients' basal insulin and a basal plus bolus correction insulin regimen is the preferred treatment with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, prandial, and correction components is the preferred treatment for non-critically ill hospitalized patients with good nutritional intake and also for patients requiring glucocorticoid. Only gliding scale insulin use regimen in the inpatient hospital setting is strongly discouraged. If analogue insulin is unaffordable, conventional insulin can be continued being careful about more hypoglycemia while frequent monitoring is necessary. For management of diabetes in hospital setting, DKA and HHS, please refer to BES Insulin Guideline, Sections 

General precautions are mandatory for patients and caregivers, to prevent contracting COVID-19 59 (Table 7) .

Pregnant women experience immunological and physiological changes according to the CDC which might make them more susceptible to viral respiratory infections, including COVID-19.

Women with pre-existing diabetes have been identified as being more vulnerable to the severe 60 effects of COVID-19. Additional tests at antenatal visit should include HbA 1c , renal and thyroid function, and urinary albumincreatinine ratio (ACR) and fundoscopy where possible. Face-to-face review is needed if early, this should coincide with the 11-14-week scan. All women with preexisting diabetes should be educated about SMBG, diet chart and sick day rules, information on hypoglycemia avoidance, prescription for folic acid and aspirin. Close and regular phone or email communication between obstetric and diabetic teams is essential to plan care and follow up. Women affected by COVID-19 should be advised to more frequent review of SMBG report.

In view of the prolonged waiting period in hospital, 61 2-hour oral glucose tolerance test (OGTT) may be postponed in this COVID 19 situation. For women having high risk of GDM the following modifications (as per Figure 2 ) could be used.

All women diagnosed with GDM should have an appointment with the diabetes team who will provide glucometer training and diet advice. Where feasible, this should be done via video call. Further diabetes follow up should be done remotely. For GDM women having target glycemic control on diet only, no further hospital visits for diabetes test are needed. They will contact with diabetes team if they have >3 abnormal blood glucose levels/week or >10-15% of all readings. Postpartum screening for maternal dysglycemia should be deferred until after the COVID-19 pandemic is over.

Health-care professionals with diabetes and those with age >60 years should be deployed away from front-line clinical duties where possible. 2 For cases in which this is not possible or desirable, high-grade protection or increased protection should be used. 2 All healthcare personnel should adhere to standard precautions when caring for patients with SARS-CoV-2 infection, using respirator face mask, isolation gown, face shield or goggles, and performing hand hygiene before putting on gloves. 62 SARS-CoV-2 infection patients whether confirmed or possible should wear a facemask when being evaluated medically. 62 Any HCP who develops fever or symptoms consistent with COVID 19 should immediately self-isolate and contact to arrange for medical evaluation and testing. 62

Individuals with adrenal insufficiency have an increased rate of respiratory infection-related deaths, possibly due to impaired immune function reported in studies. 63 After diagnosis of COVID-19, a prompt modification of the replacement dose as indicated for the "Sick days" should be established when minor symptoms appear. In general, patients should double their usual glucocorticoid dose to avoid adrenal crisis. Additionally, patients are also recommended to have sufficient stock at home of steroid pills and injections, ideally a 90-day preparation. 63 In case of inability to take oral glucocorticoids due to vomiting/diarrhea, injectable steroids should be initiated and hospital admission should be advised. 64 If adrenal crisis is suspected (fever, hypotension), 100-200 mg hydrocortisone IV 4-6 hourly should be initiated.

Individuals with uncontrolled Cushing's syndrome of any origin are at higher risk of infection in general. 63 If experiencing fever or cough supportive treatment should be initiated. In case of shortness of breath, hospital admission should be advised.

In COVID-19 patients admitted in hospital, routine thyroid function tests are not recommended. There is no benefit of levothyroxine treatment in patients with euthyroid syndrome. 65 Patients with thyrotoxicosis should continue taking medications as prescribed as those with uncontrolled thyrotoxicosis may be at higher risk of complications (such as thyroid storm) from any infection. Patients on corticosteroids or immunosuppressive agents for thyroid eye disease are more susceptible and are at high risk of severe illness from COVID-19 and such patients need to take more precautions. 66 Carbimazole induced agranulocytosis and subacute thyroiditis should be kept in mind as DovePress differentials in patients presenting with sore throat. According to recent case reports, COVID-19 infection may cause subacute thyroiditis. Hypothyroidism patients should continue taking levothyroxine treatment as suggested. 66 

While there is no evidence of increased risk of COVID-19 to patients with bone and mineral metabolism disorders, the unprecedented global lockdowns have significantly affected their care. It is advisable for those on medications such as denosumab and romosozumab to receive timely infusions, however, infusions of bisphosphonates such as Zoledronic acid may be deferred due to their long half-life. 67 

Central and nephrogenic diabetes insipidus (DI) pose a particular challenge due to reduced availability of laboratory (electrolyte) testing. An opinion piece recently highlighted this challenge, encouraging the practice of once a week aquaresis by omitting one dose of vasopressin in individuals with existing DI. 68

The fight against COVID-19 has been proven to be a challenging one. As in every war, it's the duty of the frontline fighters to protect the vulnerable group with utmost preference -the elderly and those with comorbid conditions. Therefore, all healthcare personnel should make the best use of updated knowledge and skills to ensure adequate protective measures and timely treatment for COVID-19 patients having diabetes, other endocrine diseases or any other comorbidities.

Effects of hypertension, diabetes and coronary heart disease on COVID-19 diseases severity: a systematic review and meta-analysis. medRxiv

Practical recommendations for the management of diabetes in patients with COVID-19

A cross-sectional Study to evaluate diabetes management, control and complications in patients with type 2 diabetes in Bangladesh

COVID-19 and Italy: what next?

Prevalence of diabetes and hypertension and their associated risks for poor outcomes in Covid-19 patients

Diabetic patients with COVID-19 infection are at higher risk of ICU admission and poor short-term outcome

World Health Organization

The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)-China

Clinical Characteristics of 82 Death Cases with COVID-19. medRxiv

Saudi Scientific Diabetes Society Position Statement: management of diabetes mellitus in the pandemic of COVID-19

Diabetes and COVID-19: evidence, current status and unanswered research questions

Diabetes is a risk factor for the progression and prognosis of COVID-19

SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor

The sweeter side of ACE2: physiological evidence for a role in diabetes

Characterization of ACE and ACE2 expression within different organs of the NOD mouse

Binding of SARS coronavirus to its receptor damages islets and causes acute diabetes

Glycemic targets: standards of medical care in diabetes-2020

Expert recommendation on glucose management strategies of diabetes combine with COVID-19

Diabetes self-management amid COVID-19 pandemic

Continuous glucose monitor interference with commonly prescribed medications: a pilot study

RSSDI consensus on self-monitoring of blood glucose in types 1 and 2 diabetes mellitus in India

Continuous glucose monitoring in the surgical intensive care unit: concordance with capillary glucose

Timely blood glucose management for the outbreak of 2019 novel coronavirus disease (COVID-19) is urgently needed

Sick day rules: how to manage Type 2 diabetes if you become unwell with coronavirus and what to do with your medication

Medscape diabetes and endocrinology, glucose control key with COVID-19 in diabetes

ESPEN expert statements and practical guidance for nutritional management of individuals with sars-cov-2 infection

Dublin: Irish Longitudinal Study on Ageing (TILDA)

Inhibition of H1N1 influenza virus infection by zinc oxide nanoparticles: another emerging application of nanomedicine

Vitamin C intake and susceptibility to pneumonia

International Diabetes Federation

Prone Position in Management of COVID-19 Patients; a Commentary

National Guidelines on Clinical Management of COVID-19. Version 8.0. Dhaka: Directorate General of Health Services

Dhaka: Diabetic Association of Bangladesh

Advice for healthcare professionals on coronavirus (Covid-19) and diabetes

Mental health and psychosocial considerations during the COVID-19 outbreak.World Health Organization

COVID-19 outbreak: guidance for people with diabetes

Role of AMP-activated protein kinase in mechanism of metformin action

Basic Neurochemistry (Eighth Edition)

Metformin in COVID-19: a possible role beyond diabetes

Assessment of risk, severity, mortality, glycemic control and antidiabetic agents in patients with diabetes and COVID-19: a narrative review

Non-insulin anti-diabetic agents in patients with type 2 diabetes and COVID-19: a critical appraisal of literature

A SARS-CoV-2-human protein-protein interaction map reveals drug targets and potential drug-repurposing

COVID-19 and diabetes: can DPP4 inhibition play a role?

DPP-4 inhibitors and risk of infections: a meta-analysis of randomized controlled trials

Dipeptidyl-peptidase-4 inhibitors in type 2 diabetes and COVID-19: from a potential repurposed agent to a useful treatment option

Should anti-diabetic medications be reconsidered amid COVID-19 pandemic?

COVID-19 and diabetes management: what should be considered?

Coronavirus infections and type 2 diabetes-shared pathways with therapeutic implications

Empagliflozin attenuates transient cerebral ischemia/reperfusion injury in hyperglycemic rats via repressing oxidative-inflammatory-apoptotic pathway

Thiazolidinediones as anti-inflammatory and anti-atherogenic agents

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Prevalence of co-morbidities and their association with mortality in patients with COVID-19: a systematic review and meta-analysis

Melbourne: Royal Australian College of General Practitioners

Diabetes and Cardiovascular Disease (D&CVD) EASD Study Group. Issues of cardiovascular risk management in people with diabetes in the COVID-19 era

Comprehensive Medical Evaluation and Assessment of Comorbidities: standards of Medical Care in Diabetes-2021

COVID: Diabetes): guidance For Managing Inpatient Hyperglycaemia

London Inpatient Diabetes Network-COVID-19. Guidelines for the management of diabetes services and patients during the COVID-19 pandemic

Guidance for maternal medicine in the evolving coronavirus (COVID-19) pandemic: information for healthcare professionals, Version 2.4. London: Royal college of obstetrics and gynecologists

Urgent updatetemporary alternative screening strategy for gestational diabetes screening during the COVID-19 Pandemic: a Joint Consensus Statement from the Diabetes Canada Clinical Practice Guidelines Steering Committee and the Society of Obstetricians and Gynecologists of Canada

Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to SARS-CoV-2. Washington: Center for Disease Control

COVID-19 and endocrine diseases, A statement from the European Society of Endocrinology

Coronavirus disease 2019 and thyroid disease: position statement of Indian Thyroid Society

AACE position statement: Coronavirus (COVID-19) and people with thyroid disease

Foundation NO patients and providers fact sheet: injections or infusions of osteoporosis medications during the COVID-19 Pandemic cdn.nof.org2020. Arlington: National Osteoporosis Foundation

Hyponatremia in patients with infectious diseases

Original research, review, case reports, hypothesis formation, expert opinion and commentaries are all considered for publication. The manuscript management system is completely online and includes a very quick and fair peer-review system

The authors report no conflicts of interest in this work.