Prevention and management of COVID-19 among patients with diabetes: an appraisal of the literature

Diabetologia (2020)


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The coronavirus disease 2019 (COVID-19) pandemic has emerged as one of the greatest challenges faced by humankind in the recent past. People with diabetes and related comorbidities are at increased risk of its complications and of COVID-19-related death. Older age, multi-morbidity, hyperglycaemia, cardiac injury and severe inflammatory response are predictors of poor outcome. The complex interplay between COVID-19, diabetes and the effects of related therapies is being explored. Most patients experience a mild illness with COVID-19, while people with diabetes are at increased risk of severe disease. Optimising glycaemic control and adopting measures to prevent disease spread are critical aspects. The management of mild disease is supportive, while very many immunomodulatory and antiviral therapies are being investigated for the treatment of severe disease. Several of these agents have specific considerations for use in people with diabetes. Since mass population lockdowns are considered a key step in controlling disease spread, it follows that, in addition to the direct vulnerability to severe COVID-19, people with diabetes can be affected by limited access to healthcare, insulin, other medications and blood glucose monitoring equipment. Measures to prevent disease spread at the individual and community level are the key to mitigating the rapidly escalating pandemic, while agents for chemoprophylaxis and vaccines are being explored. People with diabetes should be recognised as a vulnerable group for complicated disease and are at risk during times of disturbed social systems. Strategies are needed to safeguard the health of patients with diabetes during the pandemic. This review summarises the current knowledge and perceived challenges for prevention and management of COVID-19 in people with diabetes.


Key points

People with diabetes developing COVID-19 are at increased risk for complications and mortality

Adherence to healthy diet and lifestyle and access to healthcare is limited by infection control measures in the community, such as lockdown, self-isolation and quarantine

General precautions to prevent COVID-19 infection are critical for people with diabetes and their families. Patients with multiple comorbidities need extra caution

Continuation of good dietary practices, safe physical activities and regular glucose monitoring should be encouraged

Measures such as telemedicine services and drug dispensing for extended durations or by home delivery should be adopted to reduce exposure of diabetes patients while ensuring uninterrupted continuity of care

People with diabetes who develop COVID-19 should continue their routine medications unless the illness is severe

For severe COVID-19 in diabetes patients, glycaemic control is best achieved with insulin SGLT2 inhibitors are best discontinued unless the illness is mild

ACE inhibitors/ARBs should be continued unless contraindications develop or further evidence emerges against their use

Individualised decisions should be taken on continuing aspirin and statins

Research into pharmacological therapies for treatment and prevention of COVID-19 in people with diabetes is urgently needed


From the article


Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus, has become a pandemic within a few months after it was first described in Hubei province in China. At the time of writing it had affected over 1,800,000 individuals in more than 200 countries and territories worldwide causing over 110,000 deaths [1]. The USA and certain regions of Europe are currently experiencing the highest disease burden while it is apparently coming under control in China [2].

COVID-19 is highly transmissible from person to person through respiratory secretions. The virus enters through mucous membranes of the upper respiratory tract, later affecting lungs. [3]. In the majority of cases, COVID-19 is a mild illness, while some people develop severe disease characterised by respiratory compromise (dyspnoea; respiratory rate ≥ 30 breaths per minute; blood oxygen saturation ≤ 93%; PaO2:FiO2 < 300; and/or pulmonary infiltrates on >50% of lung fields on radiological imaging) [4]. A minority of patients develop critical disease with septic shock or respiratory and/or multi-organ failure. Fewer than 5% of those affected develop serious or critical illness [5], which is likely to be an over-estimate since sub-clinical infection rates in the community are unknown. Secondary pneumonic bacterial infection can be an additional problem.


Future directions

COVID-19 has emerged as one of the greatest challenges for humankind after the Second World War. Identification of effective preventive and treatment strategies is urgently needed. People with diabetes and related comorbidities have been shown to fare worse, although the pathophysiological and molecular mechanisms behind this link are not yet fully understood. Researchers and authorities worldwide should take urgent steps to answer critical questions in the prevention and management of COVID-19 and the protection of people with diabetes (Text box: Unanswered questions).

It is imperative to establish standard case definitions, data collection, recording and sharing strategies and operational guidelines to allow comparison and analysis of data. Standardisation of research protocols and identification of research priorities is essential to utilise time and resources productively. The role of pharmaceutical agents in the prevention and treatment of COVID-19, in terms of their efficacy, safety and cost effectiveness, should be evaluated as a priority. Further data are needed, especially looking at the effects of ACEI/ARBs and SGLT2 inhibitors in those infected, as well as in the severely ill.

Healthcare systems should adopt strategies for case detection and treatment while maintaining care and supply of essential medicines for people with chronic diseases such as diabetes, to reduce morbidity and mortality risk due to such diseases during this period. The strategic utilisation of human resources in healthcare services and safeguarding their health is a timely need. The current challenge for healthcare systems should be an opportunity to improve service provision, learn from successful regional and global strategies and prepare for future challenges of greater magnitude. The pandemic also highlights the need for joined-up public health measures and care-for-all policies.



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