key: cord-0965833-hidtvrgd authors: Das, Ashok Kumar; Kalra, Sanjay; B, Krishnakumar; Sharma, Kamal; John, Mathew; Nair, Tiny; Shaikh, Shehla; Khandilwal, Deepak; Priya, Gagan; Dutta, Deep; Gangadhar, Prathosh; Dhingra, Atul; Tiwaskar, Mangesh; Shukla, Rishi; Das, Sambit; Baruah, Manash Pratim; Gangopadhyay, Kalyan Kumar; Ramakrishnan, Santosh; Deshmukh, Vaishali; Dasgupta, Arundhati; Kumar, GVijaya; Pandey, Neelam; Joshi, Amya; Surana, Vineet Kumar; Punyani, Hitesh; Shah, Parag; Rattan, Aditya; Chandrasekaran, Sruti; Asirwatham, Arthur title: Cardiometabolic vigilance in COVID-19 and resource husbandry in resource-challenged times: Clinical practice- based expert opinion date: 2020-11-20 journal: Diabetes Metab Syndr DOI: 10.1016/j.dsx.2020.11.014 sha: 632d4f0c9c6d4e0b0bb7703c97db5faa3dcf1e80 doc_id: 965833 cord_uid: hidtvrgd BACKGROUND AND AIMS: The ongoing pandemic of coronavirus disease 2019 (COVID-19) is rapidly evolving, thereby posing a profound challenge to the global healthcare system. Cardiometabolic disorders are associated with poor clinical outcomes in persons with COVID-19. Healthcare challenges during the COVID-19 pandemic are linked to resource constraints including shortage of Personal Protective Equipment's (PPE), laboratory tests and medication. In this context, a group of clinical experts discussed the endocrine and cardiology vigilance required in times of COVID-19. Further, the group proposed certain resource husbandry recommendations to be followed during the pandemic to overcome the constraints. METHOD: The clinical experts discussed and provided their inputs virtually. The expert panel included clinical experts comprising endocrinologists, Consultant Physicians and cardiologists from India. The panel thoroughly reviewed existing literature on the subject and proposed expert opinion. RESULTS: The expert panel put forward clinical practice-based opinion for the management of cardiometabolic conditions including diabetes mellitus and hypertension. As these conditions are associated with poor clinical outcomes, the expert panel recommends that these persons be extra-cautious and take necessary precautions during the ongoing pandemic. Further, experts also provided appropriate, affordable, available and accessible solution to the resource constraint situations in times of COVID-19 pandemic. CONCLUSION: The clinical expert opinion put forward in this article will serve as a reference for clinicians treating diabetes and cardiovascular disease during the COVID-19 pandemic. • Healthcare challenges during the pandemic are linked to resource constraints including shortage 91 of PPE, laboratory tests and medications 92 • A group of clinical experts discussed the endocrine and cardiology vigilance required in times of 93 COVID-19 94 • The expert panel put forward clinical practice-based opinion for the management of 95 cardiometabolic conditions 96 J o u r n a l P r e -p r o o f pandemic has led to the lockdown of countries, including the shutting down of other medical services 128 (including regular check-ups and monitoring). Persons with underlying comorbidities must maintain 129 optimal glycemic and vasculo-metabolic health [11, 12] . Hence, there is a need to frame certain practice 130 guidelines to monitor the cardiometabolic status of persons with underlying comorbidities, especially 131 during the COVID-19 pandemic. In this context, a group of Indian experts aimed to propose clinical 132 practice and experience based expert opinions for monitoring and managing cardiometabolic disorders 133 during the COVID-19 pandemic. Like previous viral epidemics, the presence of cardiometabolic comorbidities has been reported to be an 145 independent risk factor for increased fatality in persons with COVID-19. According to a retrospective 146 study by Zhou et • Co-prescription with OADs and insulin requires strict monitoring of blood sugar levels 212 • Beta-blockers can be continued, but it should be noted that HCQ increases levels of these drugs 213 and CV monitoring is advisable 214 • Digoxin can also be continued, but monitoring may be needed 215 Hypertension is a common comorbidity in persons with COVID-19. It is well known that ACE/ARBs 216 inhibitors are commonly used in the treatment of cardiovascular diseases, including hypertension. 217 However, earlier studies have reported the role of ACE inhibitors in upregulating ACE2 expression [21, 218 An observational study from a combined cohort of Germany and Netherlands patients, examined the 220 association between antihypertensive agents used in people hospitalized with COVID-19 infection and 221 outcomes. It demonstrated that no evidence of adverse outcomes with ACEI / ARB. Interestingly, beta 222 blockers provided beneficial role in terms of milder course after admission to hospital. Whereas there 223 was a significant association with poor outcomes in patient treated with Calcium Channel Blockers (CCB) 224 The Cardiological Society of India (CSI) has also issued a position statement in this regard, stating that 226 guideline directed drug therapy including ACEI/ARB/ARNI is to be continued in patients with pre-existing 227 heart failure. CSI also says that cardiologists should continue using these drugs to prevent mortality due 228 to heart failure and myocardial infarction, until further research on SARS-Cov-2 interaction with 229 ACEi/ARB's shows a strong reason to stop these drugs. Although diabetes has been associated with poor outcomes in persons with COVID-19, the susceptibility 295 to SARS-CoV-2 infection is not higher in people with diabetes. There is not enough data to show whether 296 people with diabetes are more likely to get COVID-19 than the general population. The American 297 Diabetes Association (ADA) has also issued statements that people with diabetes are not more prone to 298 COVID-19 than the general population [40]. "New-onset" hyperglycemia with or without diabetes has 299 been associated with COVID-19 and reinforces findings that there may be a bidirectional relationship 300 Obesity is also a risk factor for severe infection, and many persons with type 2 diabetes are obese. The 302 studies conducted during the H1N1 epidemic demonstrated severe disease in obese persons, and the 303 risk was higher in persons with abdominal obesity. Persons with abdominal obesity usually have 304 J o u r n a l P r e -p r o o f respiratory problems, including reduced ventilation of the basal lung sections, and hence there is a 305 higher risk of pneumonia and reduced oxygen saturation in these persons [42, 43] . 306 Further, certain drugs such as corticosteroids, lopinavir, ritonavir, type 1 interferons, and azithromycin 307 used in the management of COVID-19 can also worsen glucose control [39] . Available evidence on the 308 use of anti-diabetic agents is summarized in Table 1 . 309 6. It is strictly advised to follow self-quarantine; this is especially recommended for elderly people 330 with underlying comorbidities. 331 7. It is advisable to stick to ongoing therapies. However, the dosage of oral antidiabetic may need 332 to be reduced in serious symptomatic cases. 333 8. Serious symptomatic cases will need to be converted to insulins. 334 The sudden emergence of the pandemic has imposed an enormous burden on healthcare facilities. 336 Further, there is a lack of essential medications and non-availability of personal protective equipment 337 (PPE) even in countries with the best healthcare facilities. As the emergence of the disease was rapid, 338 the world was not prepared to handle a pandemic. Challenges in healthcare ( The ongoing crisis calls for an innovative approach to counteract the lack of resources -resource 343 husbandry -this is a vital concept that needs to be promoted during these hard times to combat the 344 shortage of medical resources while simultaneously providing effective treatment to the patients [56] . 345 Based on the available evidence, the expert panel put forward certain recommendations for the 363 management of cardiometabolic disorders during the pandemic (Box 1 and Fig 1) . 364 Coronavirus disease 2019 (COVID-19) Situation Report-94 World Health Organization Characteristics of and important lessons from the coronavirus disease 2019 407 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center Disease Control and Prevention Cardiovascular disease and COVID-19. 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