Covid-19 & Diabetes Treatment Guideline

• People with diabetes aren’t more likely to get COVID-19 than the general population.
• People with diabetes do face a higher chance of experiencing serious complications from COVID-19.
• The risks are similar for people with type 1 and type 2 diabetes.
• People with diabetes should comply with their local government requirements and recommendations about precautions such as social distancing and self-isolation.

When people living with diabetes are ill, their bodies react by releasing hormones to fight the illness. These hormones can be triggered by any number of conditions, such as infections, cardiovascular ischaemic events, gastroenteritis, dehydration etc.

The hormones released during an illness raise blood sugar levels and at the same time make it more difficult for insulin to lower them. For people living with diabetes, even a minor illness can lead to dangerously high blood sugar levels. This may cause life-threatening complications, such as diabetic ketoacidosis or a hyperosmolar hyperglycemic state.

• People living with diabetes, their carers, and parents of children living with diabetes should work with their healthcare team to make an illness plan
• They should discuss:
  • Their target blood sugar goal during an illness
  • How to adjust their medicines (for example how to adjust their insulin dosage and when to take insulin)
  • When to contact their healthcare team for help

• How often to check their blood sugar and ketone levels.

• When ill, extra insulin might be necessary as blood glucose levels may rise even if patients are unable to eat or drink normally.

• If a person with diabetes becomes ill, the following steps should be followed, even if the blood sugar levels are within the target range:

• Take diabetes medication as usual. Insulin treatment should never be stopped.
• Test blood glucose every four hours, and keep track of the results.
• Drink extra (calorie-free) fluid*, and try to eat as normal
• Weigh yourself every day. Losing weight while eating normally is a sign of high blood glucose.
• Check temperature every morning and evening. A fever may be a sign of infection

*drink plenty of fluids-120 to 180 ml every half an hour to prevent dehydration. It might also be necessary to drink sugary beverages if it is not possible to take in 50 grams of carbohydrates through food. The amount of sugary beverages should nevertheless be carefully controlled to prevent blood sugar levels from rising too much.

• If a person with T2D takes metformin tablets, it may be necessary to temporarily stop these tablets. This is usually advised of the person has a severe infection or becomes dehydrated.

  If it is necessary to stop taking metformin, then an alternative treatment needs to be out in place until the metformin treatment can be resumed (this may include other anti-diabetic pills or even insulin sometimes, depending on the individual levels of blood sugar rise).

  People on other oral diabetes treatment may have been provided with blood glucose testing equipment to ensure that their blood glucose levels do not fall too low (hypoglycemia) and to routinely monitor their diabetes. For those people, there is no need to test very often. During an illness, blood glucose levels usually rise. People with T2D should use the test results as a guide and aim to keep their blood glucose levels between 6 and 10 mmol/l (110 and 180 mg/dl). They may need to test their blood glucose levels at least twice a day.

• 85.9% of patients using insulins + OADs and 79.3% of patients using only insulins are not at target*3
• Three reasons for not achieving glycemic goal for people on basal insulin:
  • Fear of hypoglycaemia5
  • Lack of experience in self-management4
  • Inadequate insulin titration4,5

*Target HbA1c <7%; The IDMPS (N=1936) was a large, observational study program, collating data in seven individual waves from 2005 to 2017. The data from wave 7 (2016–2017) describing real-world acheivement of glycemic targets was reported in this study

• Despite a wide range of antidiabetic therapies at our disposal, many barriers exist that prevent us from achieving good glycemic control for all of our patients with T2DM
• Patient concerns:
  • Hypoglycemia
  • Weight gain
  • Regimen complexity
  • Retaining driving license
• Physician concerns:
  • Insulin titration
  • Adherence
  • Multimorbidity
  • Adverse events

*From time when HbA1c was ≥7.0%, ≥7.5% or ≥8.0%; **From time when HbA1c was ≥7.5%.

• Insulin treatment is now recognized as consisting of two distinct periods, each having a potentially different risk of hypoglycemia
• Initiation and titration: titration period in clinical trials is generally defined as the first 8–12 weeks after insulin initiation.⁹,¹⁰ 
• Maintenance period: Period where the insulin dose is kept stable, unless a dose adjustment is necessary for safety reasons (e.g. hypoglycemia) ¹¹
• Many patients fail to reach their glycemic targets after initiating insulin therapy, partly due to a lack of up-titration in their insulin dose.¹²

• Mean HbA1c exhibits steepest decrease in first 3 months, before remaining stable for the remaining period

Observational retrospective analysis of Cegedim Strategic Data from 40,627 patients with T2DM ± OADs/GLP-1RA initiating basal insulin from France, Germany, Italy, Spain, UK and USA (2008–2012)

• Risk of hypoglycemia after 24 months if patient experiences hypoglycemia

Observational retrospective analysis of Cegedim Strategic Data from 40,627 patients with T2DM ± OADs/GLP-1RA initiating basal insulin from France, Germany, Italy, Spain, UK and USA (2008–2012)

T2DM, Type 2 diabetes mellitus; OAD, Oral anti-diabetic; IDMPS, the International Diabetes Management Practices Study; GLP-1 RA; Glucagonlike peptide-1 receptor agonists; RCTs, Randomized control trials; BI, Basal insulin; CI, Confidence interval; OR, Odds ratio