As the country struggles to come up with a public health response to the novel coronavirus pandemic, endocrinologists are warning people with type 1 and type 2 diabetes of their increased susceptibility for contracting the disease and how to best be prepared with an adequate supply of diabetes medications and testing supplies.
“Diabetes is listed by the CDC as one of the chronic illnesses that does put you at higher risk for developing more serious complications of COVID-19,” Neena A. Xavier, MD, FACE, director of didactic education and assistant professor in the department of physician assistant studies at Brenau University in Georgia, told Healio. “Diabetes does affect your immune system and it does affect your ability to fight off disease. This pertains to a large portion of our patient population. We must emphasize the importance of prevention and, if needed, social distancing for high-risk people.”
In an article published in February in JAMA, Dawei Wang, MD, of the department of critical care medicine at Zhongnan Hospital of Wuhan University in Hubei, China, and colleagues wrote that among a cohort of 138 confirmed COVID-19 cases in China as of Feb 11, 2.3% overall were fatal; however, the fatality rate substantially increased with the presence of comorbid diseases, including cardiovascular disease (10.5%) and diabetes (7.3%).
Increased risk, vigilance
In a blog post published Friday by the Association of Diabetes Care and Education Specialists, Melissa Young, PharmD, RPh, BC-ADM, CDE, professor in the department of pharmacotherapy at the University of Utah School of Medicine, wrote that chronic hyperglycemia can negatively affect immune function and increase risk for morbidity and mortality due to an infection, such as COVID-19, and any associated complications.
Patients with diabetes are more likely to develop more serious complications of COVID-19.
“What is the risk for people with diabetes who have contracted COVID-19? Among 26 fatality cases in Wuhan, China, major comorbid diseases were hypertension (53.8%), diabetes (42.3%), congestive heart disease (19.2%) and cerebral infarction (15.4%),” Young wrote, citing an article published last month in the Journal of Clinical Medicine. “As with seasonal influenza, new abstract data associated COVID-19 with potentiating myocardial damage and identified underlying CHD as a risk factor for critical complications.”
For people with diabetes who present with symptoms of the novel coronavirus, the same “sick day” rules apply as when a person with diabetes has influenza, according to Jason C. Baker, MD, assistant professor of medicine and attending endocrinologist at Cornell Medical College in New York and the founder of Marjorie’s Fund, a type 1 diabetes nonprofit with a global initiative to improve diabetes education, health care access and economic empowerment.
“In general, it seems that we as part of the diabetes community are at slightly higher risk for getting COVID-19, and if we do get it, it is slightly more complicated because we have to manage our blood glucose, which tends to fluctuate any time we have stress, like an infection,” Baker, who has type 1 diabetes, told Healio. “I’ve been making the same recommendations with this virus as I would with someone who had the flu, which is realize that any carbohydrate you eat may have two to three times the impact that you are used to it having, and that you may have a lot more insulin resistance than you are used to having. Additionally, your risk for hypoglycemia increases due to the higher doses of insulin needed. Things that were once predictable may become unpredictable in terms of the effect things will have on blood glucose.”
Baker said a person with diabetes who has flu-like symptoms should lower carbohydrate intake, stay well-hydrated and monitor blood glucose more than usual.
“There isn’t anything different to do with COVID-19 except to say, with this, we are very limited in our ability to screen for it,” Baker said. “When we recommend that people just stay home and ride it out, that can be really scary for a person with diabetes, who may need more support. I tell people to be in close contact with their provider if they don’t feel well, let their provider know if they are having issues with blood glucose, and have a support network to check on them.”
Impact on diabetes care
The increased risk for people with diabetes is changing the way some patients seek care, Baker said.
“This is a situation that is making people afraid to go in for care in person, so a lot of our visits are being converted to video,” Baker said. “Not all providers have that opportunity, but we are asking that all non-urgent, nonessential visits be delayed, that all nonessential lab work be delayed.”
Additionally, many patients have started inquiring about running out of insulin or other diabetes medications should there be a supply chain interruption, Baker said.
“This is leading to a lot of messaging, patients asking if they can increase supply or have a provision for adequate insulin, test strips and pump supplies,” Baker said. “It has opened up the realization that a lot of people in the diabetes community do not have a good emergency plan in place. To me, this is a reminder of the need for that plan. I don’t think it will come to the point where we are literally without medications, but I am telling people to use this as an opportunity to build up your emergency supply.”
“For our patients with uncontrolled diabetes or older patients with diabetes, we are asking if we can give them an extra prescription so they have a supply,” Xavier said. “We are also offering to switch patients to mail order, so they can receive 90-day supplies and have medications delivered direct to the home.”
Xavier said patients have worked with providers to prepare.
“We have not had a confirmed case of COVID-19, so we are using education to help stem the spread," Xavier said. "We have used messaging that states if you have symptoms that are concerning, please call the clinic. Do not come into the clinic and sit in a waiting room [with symptoms]. Patients are truly concerned and actively engaged in their own health. They have listened, and if they are concerned about their symptoms, they have been calling.”
The emphasis remains on preventing spread of a communicable disease.
“We must all have the same message — we care about you, we want what is best for you, and we believe in the power of preventive medicine,” Xavier said. “The heart of the matter is the trajectory is going up every day. If we practice prevention and isolation, we can change the trajectory and potentially save thousands of lives.” – by Regina Schaffer
ADCES. COVID-19: Risky business for people with diabetes? Available at: https://www.diabeteseducator.org/news/perspectives/aade-blog-details/adces-perspectives-on-diabetes-care/2020/03/12/covid-19-risky-business-for-people-with-diabetes. Accessed: March 16, 2020.
Wang D, et al. JAMA. 2020; doi:10.1001/jama.2020.1585.
Disclosures: Baker and Xavier report no relevant financial disclosures.