The coronavirus disease (Covid-19) has resulted in blood glucose levels shooting through the roof for diabetics who are struggling because of factors ranging from inability to contact their physicians and visit hospitals due to the fear of the infection, non-compliance with medication regimens because of reduced income and shortages of insulin and glucose strips, and weight gain, according to experts.
A new paper from a consortium of leading Indian diabetologists and endocrinologists outlines five possible scenarios that have been leading to high sugar levels in people with Covid-19 and recommends actions to prevent complications and death.
“Diabetes does not raise the risk of getting coronavirus disease (Covid-19), but people with diabetes who get infected are at a higher risk of severe disease, complications and death. Previous studies have shown that 70% patients with diabetes in India have poor glycaemic control, and many have diabetes-related complications. The paper has outlined five scenarios with implications on disease progression and severity that have been observed in patients since March, of which two are new,” said Anoop Misra, who led the consortium of experts from across India who published the study in the journal, Diabetes and Metabolic Syndrome: Clinical Research & Reviews.
The key factors that increase fatality among Covid-19 patients with diabetes are defects in T-cell immunity, baseline high levels of cytokines and comorbidities such as obesity, coronary heart disease, hypertension and chronic kidney disease, among others.
High blood glucose levels at the time of hospitalisation may be due to undetected diabetes or recent weight. “What has also been observed is people with undiagnosed diabetes converting to full-blown diabetes after Covid-19 infection due to multiple factors, such as unhealthy diet, low or no exercise, use of steroids, and mental stress. Our study from Delhi found 40% people gained weight during the lockdown, with 16% gaining 2-5 kg during 49 days of lockdown,” said Misra, who is the chairman of Fortis Center of Excellence for Diabetes, Metabolic Diseases and Endocrinology in New Delhi.
Nikhil Tandon, professor of endocrinology, All India Institute of Medical Sciences, New Delhi, said: “Unmasking of an undiagnosed disease on hospitalisation is not uncommon, which could be stress-response hyperglycaemia or due the use of steroids.”
The paper said unwarranted use of dexamethasone in mild Covid-19 infection and other seasonal flu increases the risk of hyperglycemia. “High fasting blood glucose at the time of hospitalization in people not known to have diabetes puts them at higher risk for mortality than those who have normoglycaemia (normal blood sugar),” it said.
Another scenario is hyperglycemia in pregnancy, which is a grey area in the absence of studies on pregnant women with diabetes and Covid-19. “We recommend pregnant antenatal checks, nutritionist, and diabetes educators through teleconsultations, avoid labs and intensively control their diabetes…,” Misra said.
The fourth scenario that affects 90% of diabetics is controlling diabetes on hospitalisation because of pre-existing diabetes and its complications, an infection attacking the pancreas, use of steroids to treat Covid, and stress. “Posing challenges are triggers for hyperglycemia is cytokine storm, use of corticosteroids, ketoacidosis and hyperosmolar states, inability to monitor blood glucose levels because of reduced contact between healthcare worker and patients, and non-inclusion of diabetes expert…,” the paper noted.
The fifth scenario is new onset of diabetes, which is now being reported during Covid -19 infection because Ace-2 (angiotensin converting enzyme-2) receptors, which the new coronavirus binds to enter human cells. This can lead to the destruction of insulin-producing beta cells in the pancreas. Studies show 17% Covid-19 patients have some disruption of pancreatic cells, among them insulin producing cells, which leads to rapid deterioration of condition.
“People with established disease deferring clinical visits is feasible and not a problem if they get their investigations, including blood work done regularly and consult through text or phone…” said Tandon.