key: cord-0777785-fx5w1e5h
authors: Goyal, Alpesh; Gupta, Setu; Gupta, Yashdeep; Tandon, Nikhil
title: Proposed guidelines for screening of hyperglycemia in patients hospitalized with COVID-19 in low resource settings
date: 2020-05-29
journal: Diabetes Metab Syndr
DOI: 10.1016/j.dsx.2020.05.039
sha: 08318322981513cea4b550d679529af9e545b73e
doc_id: 777785
cord_uid: fx5w1e5h

BACKGROUND AND AIMS: The coronavirus disease 2019 (COVID-19) pandemic has immensely strained the healthcare system worldwide. Diabetes has emerged as a major comorbidity in a large proportion of patients infected with COVID-19 and is associated with poor health outcomes. We aim to provide a practical guidance on screening of hyperglycemia in persons without known diabetes in low resource settings. METHODS: We reviewed the available guidelines on this subject and proposed an algorithm based on simple measures of blood glucose (BG) which can be implemented by healthcare workers with lesser expertise in low resource settings. RESULTS: We propose that every hospitalized patient with COVID-19 infection undergo a paired capillary BG assessment (pre-meal and 2-h post-meal). Patients with pre-meal BG < 7.8 mmol/L (140 mg/dL) and post-meal BG < 10.0 mmol/L (180 mg/dL) may not merit further monitoring. On the other hand, those with one or more value above these thresholds should undergo capillary BG monitoring (pre-meals and 2 h after dinner) for the next 24 h. When two or more (≥50%) such values are significantly elevated [pre-meal ≥8.3 mmol/L (150 mg/dL) and post-meal ≥11.1 mmol/L (200 mg/dL)], pharmacotherapy should be immediately initiated. On the other hand, in patients with modest elevation of one or more values [pre-meal 7.8–8.3 mmol/L (140–150 mg/dL) and post-meal 10.0–11.1 mmol/L (180–200 mg/dL)], dietary modifications should be initiated and pharmacotherapy considered only if BG control remains suboptimal. CONCLUSION: We highlight strategies for screening of hyperglycemia in persons without known diabetes treated for COVID-19 infection in low resource settings. This guidance may well be applied to other settings in the near future.

The coronavirus disease 2019 (COVID-19) pandemic has resulted in an unprecedented rise in admissions in dedicated COVID facilities. A significant proportion of patients with COVID-19 have comorbidities such as diabetes, hypertension and cardiovascular disease, which associate with poor disease outcomes [1] [2] [3] . Besides, the COVID-19 infection could itself induce new onset diabetes [4, 5] . While the importance of intensive glycemic control in persons with diabetes and COVID-19 infection has been emphasized [6] [7] [8] [9] [10] , we aim to highlight the strategies for screening of hyperglycemia in persons without known diabetes in low resource settings.

Hyperglycemia is an established risk factor for poor clinical outcomes and mortality in hospitalized patients. However, the prognosis is worse in patients with undiagnosed diabetes compared to those with a known history of diabetes [11] . The Endocrine Society clinical practice guidelines for inpatient management of hyperglycemia recommend that all hospitalized patients regardless of the diagnosis of diabetes undergo laboratory blood glucose (BG) testing on admission [12] . Patients without known diabetes and BG >7.8 mmol/L (140 mg/dL) should undergo bedside testing by a point-of-care device for the next 24-48 hours, and appropriate treatment initiated in those with persistently high BG (>7.8 mmol/L or 140 mg/dL). Measurement of glycated hemoglobin (HbA1c) is also recommended in such individuals to distinguish stress hyperglycemia (HbA1c <6.5%) from previously unrecognized diabetes (HbA1c ≥6.5%) [10] . Similarly, the American Diabetes Association (ADA) guidelines suggest BG testing at admission in all hospitalized patients, HbA1c in those with BG greater than 7.8 mmol/L (140 mg/dL), and initiation of treatment in cases with persistent hyperglycemia (≥ 10.0 mmol/L or 180 mg/dL) [13] .

We need to appropriately tailor the available guidance to low resource health care settings, where facilities for testing of HbA1c and plasma glucose may not be readily available.

Further, the burden of tests performed may exceed capacity of healthcare staff available to interpret and act on their results, thus highlighting the need for algorithms based on simple measures of BG which can be implemented by healthcare workers with lesser expertise.

We propose that every hospitalized patient with COVID-19 infection undergo a paired capillary blood glucose assessment (pre-meal and 2-hour post-meal). We prefer paired BG readings over single random BG measurement because: a) biological variability is greater for post-prandial compared to fasting BG [14] , hence, a decision based on random BG performed in postprandial state alone may be erroneous, b) interpretation of a BG value depends upon its relation to timing of meal intake, hence, adoption of a uniform threshold (RBG >7.8 mmol/L or 140 mg/dL) without relating it to meal intake may not be appropriate.

Patients with pre-meal BG <7. 

The proposed algorithm may aid in early recognition and management of in-hospital hyperglycemia and has a potential to improve clinical outcomes associated with COVID-19

infection. While capillary testing may suffer from inaccuracy, especially at extremes of BG values [15] , it is easily available, cost-effective and remains a feasible option in low resource settings.

It should be ensured that the blood glucose monitors used for this purpose are accurate and as per prescribed standards since erroneous results may result in misclassification and wrong treatment. Several pre-analytical, analytical and post-analytical factors affect the performance of blood glucose meters which should be carefully looked into [16] . Our pragmatic approach of using capillary BG testing for diagnosis and management of hyperglycemia could be supplemented with fasting plasma glucose and HbA1c measurement, where feasible.

The diagnosis and treatment plan should be reviewed again at the time of hospital discharge. 

To conclude, this commentary highlights strategies for screening of hyperglycemia in persons without known diabetes treated for COVID-19 infection in low resource settings. This guidance may well be applied to other settings in the near future.

YG conceived the idea of this paper. AG, SG and YG wrote the first draft of the manuscript which was read and edited by NT. All authors approved the final version of the manuscript. 

Effects of hypertension, diabetes and coronary heart disease on COVID-19 diseases severity: a systematic review and metaanalysis

Association of Blood Glucose Control and Outcomes in Patients with COVID-19 and Pre-existing Type 2 Diabetes

Diabetes mellitus is associated with increased mortality and severity of disease in covid-19 pneumonia -a systematic review, meta-analysis, and meta-regression

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

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

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

Our response to COVID-19 as endocrinologists and diabetologists

Clinical considerations for patients with diabetes in times of COVID-19 epidemic

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

Care for diabetes with COVID-19: Advice from China

Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes

Management of hyperglycemia in hospitalized patients in non-critical care setting: an Endocrine Society clinical practice guideline

Diabetes care in the hospital

Impact of analytical and biological variations on classification of diabetes using fasting plasma glucose, oral glucose tolerance test and HbA1c

Variability of capillary blood glucose monitoring measured on home glucose monitoring devices

Point-of-Care Blood Glucose Meter Accuracy in the Hospital Setting