February 23, 2018
5 min read

As widespread flu activity continues, diabetes compounds dangerous risks

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Mandy Reece
Mandy Reece
Adrian Vella
Adrian Vella

The most recent reports from the CDC suggest that this season’s influenza outbreak is on course to be one of the worst in recent years, with overall hospitalizations already topping last year’s difficult influenza season and an alarming increase in influenza-associated deaths in children and adults.

The epidemic has not spared patients with type 1 and type 2 diabetes. Even when the disease is well-managed, experts caution that influenza in the setting of diabetes puts patients at higher risk for serious complications, including pneumonia, bronchitis and sinus infections, all while causing blood glucose levels to fall to potentially dangerous levels.

“I’m based in a diabetes education department within an internal medicine/family medicine office, and we have been inundated with flu,” Mandy Reece, PharmD, CDE, BC-ADM, FAADE, vice chair and associate professor of pharmacy practice at Philadelphia College of Osteopathic Medicine, Georgia Campus, told Endocrine Today. “It’s all patients, with and without diabetes. It’s the worst we’ve seen since about 2010.”

In a February press briefing on nationwide influenza activity, the CDC reported overall hospitalizations this influenza season were higher than the 2014-2015 season for the same period, with the number of influenza-related hospitalizations predicted to exceed the 710,000 seen during the 2014-2015 influenza outbreak. As of mid-January, more than 152 million doses of influenza vaccine have been shipped nationwide, according to the CDC; however, there are also reports of spot shortages of antiviral medications, such as oseltamivir (Tamiflu, Genentech), and rapid influenza tests.

“Right now, one of the biggest health threats we are facing is influenza,” Anne Schuchat, MD, acting director of the CDC, said during the press briefing. “Flu is incredibly complex and difficult to predict, and this season is a somber reminder of why flu is one of the world’s greatest public health challenges.”

Increased risk

In addition to the compounded health risks that accompany influenza and diabetes, patients with diabetes are more vulnerable to secondary infections after influenza than healthy adults, said Adrian Vella, MD, professor of medicine and consultant in the division of endocrinology, diabetes, metabolism and nutrition at Mayo Clinic in Rochester, Minnesota.

“People who have poor glycemic control are likely to be immunosuppressed and, therefore, are more susceptible to secondary infections after the flu,” Vella told Endocrine Today. “The second thing is that flu takes every person as it finds him, so to speak. So, the existence of any underlying complications of diabetes will exacerbate things.”


A patient with diabetes who may be susceptible to volume overload due to ischemic cardiomyopathy on diuretics and fluid restrictions, for example, is at greater risk for dehydration, Vella said, whereas NSAIDs used for fever or muscle aches due to influenza can worsen diabetic nephropathy.

“Additionally, people with problems maintaining gait and station because of peripheral neuropathy are going to be more susceptible to falls if they are weaker or dehydrated,” Vella said. “There are all these little factors, which, taken together, can add up to produce significant impairment.”

Patient management

Clinicians and diabetes educators must work closely with patients with diabetes diagnosed with influenza, Vella said, to make sure patients are aware of steps they must take to avoid worsening symptoms and hospitalization.

“Someone who is running a temperature may be a very different kettle of fish than someone who is running a temperature, has severe myalgia, confusion and cannot get out of a chair unaided,” Vella said. “People have to take care of their hydration and glucose monitoring and, perhaps, in some situations, monitor urine ketones.”

Additionally, health care providers must stress the importance of continuing to take any antidiabetes medications, Reece said, even if a patient is not eating as much due to illness.

“Patients must also keep in mind that they need to consume carbohydrates, about 50 g every 4 to 6 hours,” Reece said. “That could be foods like soups, popsicles, gelatin. And they must make sure they are drinking 8 oz every hour. That is essential. They may not want to drink water when they’re sick, but a zero-calorie beverage, such as diet ginger ale or diet Sprite is good.”

Vella also warned of the risk for complications with certain classes of antidiabetes medications.

“For example, SGLT2 inhibitors might increase susceptibility to diabetic ketoacidosis,” Vella said. “It’s the same thing with people taking [NSAIDs] blindly and they are not eating or drinking because they are so sick.”

Vella said patients with diabetes and influenza can institute “sick day” guidelines, eating small meals as frequently as tolerated.

Influenza remedies, interactions

In a presentation on over-the-counter drugs at the 2017 American Association of Diabetes Educators annual meeting in August, Miranda Wilhelm, PharmD, clinical associate professor at Southern Illinois University Edwardsville School of Pharmacy, said many liquid cough and cold medicines contain carbohydrate and alcohol in amounts substantial enough to affect blood glucose levels.


“The content of these ingredients is not included on the drug facts label,” Wilhelm told Endocrine Today before the presentation, adding that it is the label’s listed, but often ignored, inactive ingredients that should be carefully examined by a patient with diabetes.

“A lot of times the flavorings, the colorings, the pill binders, those are the types of ingredients listed in this section,” Wilhelm said during her presentation. “For us, this is how we can identify whether the product contains sugar or not, so we can counsel patients about how that might affect their blood glucose.”

Reece said patients should consult their diabetes educator or pharmacist before choosing an OTC product to treat influenza symptoms.

“The carbs in some of these products are overwhelming,” Reece said. “Also, alcohol can be a problem because the patient could develop hypoglycemia. The other piece for the patient to recognize is whether their cough is productive or not. Often, with the flu, the cough will be nonproductive, and they will have a difficult time sleeping because of that dry cough. For that, a product like Delsym can be good, but they need to make sure they get the sugar-free formulation.”

Patients with high blood pressure should be cautious when using decongestants, Reece said, which can further raise BP.

Diabetes educators should also counsel patients to be cautious when considering products that claim to treat multiple symptoms in one formulation, Reece said.

“They need to look for a product that has the least amount of primary ingredients as possible,” Reece said. “More ingredients are not better.”

It is equally important, Reece said, to remind patients to wash their hands with soap and water often as a prevention strategy, as well as every time they check their blood glucose.

Vella also stressed the importance of patients — older patients in particular — staying up-to-date on all vaccinations, including pneumonia and shingles vaccines. – by Regina Schaffer

For more information:

Mandy Reece, PharmD, CDE, BC-ADM, FAADE, can be reached at sararee@pcom.edu.

Adrian Vella, MD, can be reached at vella.adrian@mayo.edu.

Disclosures: Reece and Vella report no relevant financial disclosures.