key: cord-0825192-0w6lwesu
authors: Cho, Yunjung; Yoon, Kun‐Ho
title: Being caught in the perfect storm of a diabetes epidemic and the COVID‐19 pandemic: What should we do for our patients?
date: 2020-10-02
journal: J Diabetes Investig
DOI: 10.1111/jdi.13425
sha: fa8611647b116cc7c3db5630485de41ffe50cae8
doc_id: 825192
cord_uid: 0w6lwesu

The pandemic of coronavirus disease 2019 (COVID‐19) has overwhelmed the whole world since the first case was reported in Wuhan, China, in December 2019. The infection, called acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2), induces various symptoms, including fever and respiratory and enteric symptoms, but some people are asymptomatic.(1,2) Although the fatality rate of COVID‐19 is lower than that of SARS‐CoV‐1 and middle east respiratory syndrome coronavirus (MERS‐CoV), the absolute number of fatalities due to COVID‐19 is quite high because of the high prevalence of the viral infection.

(WHO), as of 14 September 2020, more than 30 million people have been confirmed to be infected with COVID-19, more than 900 thousand of whom have died. 4 A major concern is that this trend is continuing around the world. Even today, nine months after the first case was reported, COVID-19 is still affecting everyone's daily life, leading to not only medical problems but also socioeconomic problems.

The prevention, early detection, and appropriate treatment of the COVID-19 infection in diabetic patients is especially important. The reason these measures are important is because several studies have shown an association between COVID-19 infection severity and diabetes.

First, statistically, the odds ratio of intensive care unit (ICU) care and mechanical ventilation for COVID-19 infection has been shown to be significantly higher in diabetic patients. 5 In a study conducted in Italy on ICU inpatients with COVID-19 infection, diabetes was the most common comorbidity, followed by hypertension, cardiovascular disorders, and hypercholesterolemia. 6 In a retrospective study comparing patients without any comorbidities and patients with diabetes without other comorbidities, a significant decrease in red blood cells and lymphocytes and a significant elevation in serum ferritin and alanine aminotransferase were observed in patients with diabetes. 7 These hematological markers are associated with secondary hemophagocytic lymphohistiocytosis, defined as hyperinflammatory syndrome. 3 The levels of various markers of inflammation and infection, such as α-hydroxybutyrate dehydrogenase, lactic dehydrogenase, neutrophils, interleukin 6 (IL-6), fibrinogen, D-dimer, and C-reactive protein, were also increased in patients with diabetes. 7 Moreover, in that study, the severity of lung inflammation, as assessed by the chest computed tomography (CT) score, was significantly higher in patients with diabetes.

This article is protected by copyright. All rights reserved Many other reports from several countries have clearly shown a link between mortality and diabetes caused by COVID-19. 8, 9 According to a report from the Korea Centers for Disease Control and Prevention released in July, a total of 299 people died from COVID-19 in Korea; 75.6% of the patients had cardiovascular diseases including hypertension, myocardial infarction, heart failure and stroke, and 47.8% of the patients had endocrine and metabolic diseases such as diabetes. [10] [11] [12] This comorbidity was higher than that of respiratory diseases, which was 26.4%, including asthma and chronic obstructive pulmonary disease. In addition, in a study of 9,148 people diagnosed with COVID-19 in Korea, the odds ratio of death in people with diabetes was 1.82 (95% CI, 1.25-2.67). 13 In the largest case series published by the Center for Disease Control and Prevention in China, 2.3% of the 4,4672 patients with positive viral nucleic acid test results died; the case-fatality rate was 10.5% in patients with cardiovascular disease and 7.3% in patients with diabetes. 1 Additionally, the Kaplan-Meier survival curves of 51,633 patients confirmed to have COVID-19 infection in Mexico revealed that the mortality rate was higher in patients with diabetes only than in those with other comorbidities without diabetes. 5 Although the odds ratio of the mortality rate showed that being under 40 years old was a protective factor (HR 0.26, 95% CI 0.23-0.29), the mortality rate (11.3%) of patients with diabetes under 40 years old was higher than the overall mortality rate (10.33%). Therefore, the prevention of COVID-19 infection in patients with diabetes in particular is very important due to the increased severity of symptoms and mortality rate.

Moreover, several studies have suggested that appropriate glycemic control is important in patients with diabetes and COVID-19 infection. In China, septic shock, acute respiratory distress syndrome (ARDS), acute kidney injury, and acute heart injury were significantly more common in diabetic patients with poor glycemic control than in those with good glycemic control. 14 Even in patients who had not previously been diagnosed with diabetes, defined as an HbA1c level of ≥6.5%, but had hyperglycemia, the mortality rate due to COVID-19 was significantly higher than in those without hyperglycemia or diabetes. 15 These studies demonstrated that appropriate monitoring and management of the blood sugar level are critical for not only patients diagnosed with diabetes but also patients newly diagnosed with diabetes during the treatment of COVID-19 infection. Vaccines have not been developed yet, and the most important methods of preventing infection are social distancing, wearing a mask, and performing proper hand hygiene.

However, maintaining an appropriate physical distance and self-isolation during the COVID-19 pandemic clearly hinders appropriate monitoring, evaluations and consultations with

This article is protected by copyright. All rights reserved patients with diabetes due to limitations in accessing medical institutions caused by a fear of becoming infected with COVID-19. In addition, patients with mild symptoms of COVID-19 infection stay in a health treatment center in Korea and require at least 3 weeks of quarantining until they test negative for the virus twice with a reverse transcription polymerase chain reaction (RT-PCR) kit. During the isolation period, it is difficult to maintain adequate lifestyle management, perform self-blood sugar monitoring and adjust one's antidiabetic medications. To solve the physical and psychological barriers to diabetic patients' access to medical institutions, remote monitoring and evaluations through various communication tools, including mobile phones, the internet and telephones, can be considered acceptable alternatives. In fact, many countries are already actively adopting mobile healthcare systems for managing diabetes patients.

In Qatar, where the incidence of diabetes patients is high, clinicians directly message patients to ensure that diabetic individuals are performing measures such as preventive measures for COVID-19 infection, self-monitoring, drug and complications management, lifestyle modifications, and psychological health management. 16 In addition, based on their medical records, diabetic patients over 50 years of age who receive insulin treatments and do not exhibit glycemic control with an HbA1c level >8% undergo a teleconsultation with a doctor and a diabetes educator. In the United Kingdom, doctors are also trying to overcome the limitations of face-to-face care and education through the management of diabetes and continuous lifestyle correction education in various ways using technology. 17 Additionally, smartphones, text messages, and the Internet of Things are being used to promote continuous education and non-face-to-face treatment for proper glucose control in patients in China, France, Italy, and the United States. 18 In Korea, temporary telemedicine is also provided for patients who have difficulty accessing medical institutions due to the need to selfisolate after testing positive for COVID-19 infection or being in close contact with an infected person. Additionally, the Korean Diabetes Association (KDA) has provided basic guidelines for preventing COVID-19 infection in diabetic patients (Table 1) . 18, 19 Accordingly, diabetic individuals who require continuous management can self-monitor their blood sugar levels and the side effects of medications at home through interviews with their doctor by telephone, and doctors can prescribe new drugs to prevent poor blood sugar control, if needed. Self-management and education among patients have been performed using the Internet of Things in several studies. In a systemic review of several meta-analyses, education and support for diabetes self-management provided using various technologies, such as the internet, text messaging, and videos enabled on smartphones, have been shown to be effective in reducing the A1c level with a complete feedback

This article is protected by copyright. All rights reserved loop. 20 Therefore, even without face-to-face treatment, effective sugar control can be achieved in patients diagnosed with diabetes through continuous patient-doctor communication using various remote technologies. However, we could not find a well-established mobile healthcare platform that is used in any country. We already have enough technology, including network systems; mobile devices for glucose, blood pressure and body temperature monitoring; and various mobile application programs for diabetes. However, authentic healthcare systems that require fees for service systems based on face-to-face contact clearly prevent the healthcare system from advancing. We urgently need to establish a new system that can be used globally; develop new payment options, such as performance payment systems; and finally, actively adopt new technologies to support patient care.

In the past, humanity has overcome medical crises successfully and made breakthroughs in medical care based on these experiences. Today, with advanced medicine, not only were we able to quickly identify SARS-CoV-2, the causative virus of COVID-19 infection, within 7 months after the first case was confirmed, but also, we implemented an RT-PCR kit for the rapid screening of suspected patients, and efforts are being made to quickly discover and develop effective treatments and vaccines. In addition, with advanced citizenship, the primary and most important methods for the prevention of infection, including keeping a physical distance, wearing masks and hand sanitization, have been practiced not only in Korea but also worldwide. Now, we must be careful and provide more care for diabetic individuals who are vulnerable to severe infections.

Relatedly, there are ongoing efforts to elucidate the association between COVID-19 and diabetes and to make it possible to actively provide health care in difficult real-life situations. To achieve this, the CoviDiab registry has been established to identify cases of diabetes caused by COVID-19 infection and severe acute complications in diabetic patients during the management of COVID-19

worldwide. 21 More studies are needed to investigate the epidemiologic features and causes of COVID-19-related diabetes and to guide treatment. Additionally, in the 21st century, we have developed several technologies that enable patient care, even in the midst of a pandemic, and many countries are working to use them appropriately to achieve strict glycemic control.

Even if the crisis is overcome successfully, pandemics caused by new infections continue to threaten humanity. During this disaster situation, it is necessary to ensure sophisticated patient care by continuing to pursue ways to enable two-way management with non-face-to-face methods, using advanced technologies that have already been proven to be beneficial, so that not only

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