Managing diabetes cases during COVID-19

COVID-19 and people with diabetes: what you need to know¹

  • 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.

How to manage diabetes during an illness? “Sick day rules” ²

What happens when people living with diabetes are ill? ²

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.

Planning ahead²

  • 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.

General guidelines to manage diabetes during an illness²

  • 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.

General guidelines for people with type 1 diabetes²

  • During a period of illness:

Insulin treatment should never be stopped The insulin dose may need to be increased and it might be necessary to take additional doses of fast-acting insulin to bring down the blood sugar levels Blood glucose levels should be checked at least every four hours Plenty of non-sweet fluids should be drunk to avoid dehydration Ideal blood sugar levels should be between 6-10 mmol/l (110-180 mg/dl)

General guidelines for people with type 2 diabetes²

  • People with type 2 diabetes should check whether they develop the following symptoms which may be indicative of high blood sugar levels:

Thirst/dry mouth Passing large amounts of urine (this can lead to dehydration) Tiredness Weight loss

General guidelines for people with type 2 diabetes on tablets²

  • 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.

Many patients are still not achieving glycemic control

  • 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

“Clinical/Therapeutic inertia”: Multiple barriers to treatment intensification in uncontrolled T2DM⁶,⁷,⁸

  • 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%.

The importance of the insulin initiation period

  • 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

Majority of titration occurred during the first 12 weeks⁹

The initiation period is a predictor for long-term outcomes

Glycemic response during first 3 months of BI therapy is a predictor for mid- to long-term glycemic control¹³

  • 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)

Hypoglycemia following insulin initiation a predictor for long-term hypoglycemia risk¹³

  • 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

    1. Diabetes.org. 2021. Diabetes and Coronavirus (COVID-19) | ADA. [online] Available at: <https://www.diabetes.org/coronavirus-covid-19> [Accessed 1 June 2021].
    2. Idf.org. 2021. News. [online] Available at: <https://www.idf.org/our-network/regions-members/europe/europe-news/196-information-oncorona-virus-disease-2019-covid-19-outbreak-and-guidance-for-people-with-diabetes.html> [Accessed 1 June 2021].
    3. ASCHNER, P., GAGLIARDINO, J., ILKOVA, H., LAVALLE-GONZALEZ, F., RAMACHANDRAN, A., KADDAHA, G., MBANYA, J., SHESTAKOVA, M., CHANTELOT, J. and CHAN, J., 2018. Poor Glycemic Control in People with T1D and T2D—Results from the International Diabetes Management Practices Study (IDMPS). Diabetes, 67(Supplement 1), p.1656-P.
    4. Dalal, M., Kazemi, M., Ye, F. and Xie, L., 2017. Hypoglycemia After Initiation of Basal Insulin in Patients with Type 2 Diabetes in the United States: Implications for Treatment Discontinuation and Healthcare Costs and Utilization. Advances in Therapy, 34(9), pp.2083-2092.
    5. Russell Jones, D., Pouwer, F. and Khunti, K., 2018. Identification of barriers to insulin therapy and approaches to overcoming them. Diabetes, Obesity and Metabolism, 20(3), pp.488-496.
    6. Khunti, K. and Millar-Jones, D., 2017. Clinical inertia to insulin initiation and intensification in the UK: A focused literature review. Primary Care Diabetes, 11(1), pp.3-12.
    7. Khunti, K., Wolden, M., Thorsted, B., Andersen, M. and Davies, M., 2013. Clinical Inertia in People With Type 2 Diabetes: A retrospective cohort study of more than 80,000 people. Diabetes Care, 36(11), pp.3411-3417.
    8. Khunti, K., Nikolajsen, A., Thorsted, B., Andersen, M., Davies, M. and Paul, S., 2016. Clinical inertia with regard to intensifying therapy in people with type 2 diabetes treated with basal insulin. Diabetes, Obesity and Metabolism, 18(4), pp.401-409.
    9. Owens, D., Traylor, L., Dain, M. and Landgraf, W., 2014. Efficacy and safety of basal insulin glargine 12 and 24 weeks after initiation in persons with type 2 diabetes: A pooled analysis of data from treatment arms of 15 treat-to-target randomised controlled trials. Diabetes Research and Clinical Practice, 106(2), pp.264-274.
    10. Ritzel, R., Roussel, R., Bolli, G., Vinet, L., Brulle-Wohlhueter, C., Glezer, S. and Yki-Järvinen, H., 2015. Patient-level meta-analysis of the EDITION 1, 2 and 3 studies: glycaemic control and hypoglycaemia with new insulin glargine 300 U/ml versus glargine 100 U/ml in people with type 2 diabetes. Diabetes, Obesity and Metabolism, 17(9), pp.859-67.
    11. European Medicines Agency. Guideline on clinical investigation of medicinal products in the treatment or prevention of diabetes mellitus (DRAFT), 29 January 2018. http://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guideline/2018/02/WC500243464.pdf
    12. Mocarski, M., Yeaw, J., Divino, V., DeKoven, M., Guerrero, G., Langer, J. and Thorsted, B., 2018. Slow Titration and Delayed Intensification of Basal Insulin Among Patients with Type 2 Diabetes. Journal of Managed Care & Specialty Pharmacy, 24(4), pp.390-400.
    13. Mauricio, D., Meneghini, L., Seufert, J., Liao, L., Wang, H., Tong, L., Cali, A., Stella, P., Carita, P. and Khunti, K., 2017. Glycaemic control and hypoglycaemia burden in patients with type 2 diabetes initiating basal insulin in Europe and the USA. Diabetes, Obesity and Metabolism, 19(8), pp.1155-1164.

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