Diabetes and COVID-19

Dear colleague,

I am writing to ask for your thoughts about whether there are any specific issues related to managing diabetes in hospitalized patients with COVID-19. Are you doing anything different from usual care (SC basal-bolus insulin for non-ICU and insulin drip for ICU patients)? Do you have experience and advice for managing COVID/DM patients on high-dose steroids?

Best regards,
Dan

------------------------------
Daniel J. Rubin, MD, MSc, FACE
Associate Professor of Medicine
Director of Clinical Research
Section of Endocrinology, Diabetes, and Metabolism
Lewis Katz School of Medicine at Temple University
Chair, Glycemic Control Taskforce, Temple University Hospital
Communications Director, Health Care Delivery & Quality Improvement Interest Group
------------------------------

We are starting to see patients here at Barnes-Jewish Hospital. The nurses have expressed discomfort going in every hour to do POC BG for insulin infusions. We are considering NPH q12 hours and adapting our sliding scales. We would then use the TDD from the slide to dose NPH the next day. Very curious to see what others are doing. Thanks for starting this discussion.


------------------------------

Paulina Cruz Bravo, MD (she/her/hers)

Assistant Professor of Medicine

Division of Endocrinology, Metabolism and Lipid Research

Washington University School of Medicine

St. Louis, MO 

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Original Message:
Sent: 03-29-2020 22:12
From: Daniel Rubin
Subject: Diabetes management in COVID-19 patients

Dear colleague,

I am writing to ask for your thoughts about whether there are any specific issues related to managing diabetes in hospitalized patients with COVID-19. Are you doing anything different from usual care (SC basal-bolus insulin for non-ICU and insulin drip for ICU patients)? Do you have experience and advice for managing COVID/DM patients on high-dose steroids?

Best regards,
Dan

------------------------------
Daniel J. Rubin, MD, MSc, FACE
Associate Professor of Medicine
Director of Clinical Research
Section of Endocrinology, Diabetes, and Metabolism
Lewis Katz School of Medicine at Temple University
Chair, Glycemic Control Taskforce, Temple University Hospital
Communications Director, Health Care Delivery & Quality Improvement Interest Group
------------------------------

Prudence suggests patients be fitted with a continuous glucose monitor such as Dexcom G6 which may be remotely monitored see e.g., https://www.glooko.com/landing/dexcom/?fbclid=IwAR0aiHotf5kHSQFzEF2f0RbB-uEecUyDDu8SJnfeCKs7xwrSTDKVYje7isw

------------------------------
Thomas Linn MSC
LONE TREE CO
------------------------------

Original Message:
Sent: 03-30-2020 13:48
From: Paulina Cruz Bravo
Subject: Diabetes management in COVID-19 patients

We are starting to see patients here at Barnes-Jewish Hospital. The nurses have expressed discomfort going in every hour to do POC BG for insulin infusions. We are considering NPH q12 hours and adapting our sliding scales. We would then use the TDD from the slide to dose NPH the next day. Very curious to see what others are doing. Thanks for starting this discussion.


------------------------------

Paulina Cruz Bravo, MD (she/her/hers)

Assistant Professor of Medicine

Division of Endocrinology, Metabolism and Lipid Research

Washington University School of Medicine

St. Louis, MO 

Original Message:
Sent: 03-29-2020 22:12
From: Daniel Rubin
Subject: Diabetes management in COVID-19 patients

Dear colleague,

I am writing to ask for your thoughts about whether there are any specific issues related to managing diabetes in hospitalized patients with COVID-19. Are you doing anything different from usual care (SC basal-bolus insulin for non-ICU and insulin drip for ICU patients)? Do you have experience and advice for managing COVID/DM patients on high-dose steroids?

Best regards,
Dan

------------------------------
Daniel J. Rubin, MD, MSc, FACE
Associate Professor of Medicine
Director of Clinical Research
Section of Endocrinology, Diabetes, and Metabolism
Lewis Katz School of Medicine at Temple University
Chair, Glycemic Control Taskforce, Temple University Hospital
Communications Director, Health Care Delivery & Quality Improvement Interest Group
------------------------------

I do not want to be argumentative but there are many clinicians who use this site and I am not sure that prudence dictates use of CGM in the hospital setting.  Prudence can also mean to proceed with caution and there is at least anecdotal evidence that these devices do not in fact always provide accurate readings - particularly with exposure to electrocautery or imaging procedures including Xrays which are often done frequently in patients who are critically ill.  As a practical matter, this would require replacing sensing devices more frequently than needs to be done in the outpatient setting and then there is a lag time of several hours before accurate data can be obtained.  There is much discussion and some guidance on this point in the Clinical Centers Discussion Group forum.  There is at least one site that may in fact have data that will provide more guidance in the near future. So at this point CGM is not the answer to the concerns that have been raised, although several institutions including our own have policies in place that allow pts to use their own CGM devices if certain qualifications are met.

------------------------------
Mary Korytkowski MD, MN, BSN
UNIV OF PITTSBURGH
PITTSBURGH PA
------------------------------

Original Message:
Sent: 03-30-2020 14:54
From: Thomas Linn
Subject: Diabetes management in COVID-19 patients

Prudence suggests patients be fitted with a continuous glucose monitor such as Dexcom G6 which may be remotely monitored see e.g., https://www.glooko.com/landing/dexcom/?fbclid=IwAR0aiHotf5kHSQFzEF2f0RbB-uEecUyDDu8SJnfeCKs7xwrSTDKVYje7isw

------------------------------
Thomas Linn MSC
LONE TREE CO

Original Message:
Sent: 03-30-2020 13:48
From: Paulina Cruz Bravo
Subject: Diabetes management in COVID-19 patients

We are starting to see patients here at Barnes-Jewish Hospital. The nurses have expressed discomfort going in every hour to do POC BG for insulin infusions. We are considering NPH q12 hours and adapting our sliding scales. We would then use the TDD from the slide to dose NPH the next day. Very curious to see what others are doing. Thanks for starting this discussion.


------------------------------

Paulina Cruz Bravo, MD (she/her/hers)

Assistant Professor of Medicine

Division of Endocrinology, Metabolism and Lipid Research

Washington University School of Medicine

St. Louis, MO 

Original Message:
Sent: 03-29-2020 22:12
From: Daniel Rubin
Subject: Diabetes management in COVID-19 patients

Dear colleague,

I am writing to ask for your thoughts about whether there are any specific issues related to managing diabetes in hospitalized patients with COVID-19. Are you doing anything different from usual care (SC basal-bolus insulin for non-ICU and insulin drip for ICU patients)? Do you have experience and advice for managing COVID/DM patients on high-dose steroids?

Best regards,
Dan

------------------------------
Daniel J. Rubin, MD, MSc, FACE
Associate Professor of Medicine
Director of Clinical Research
Section of Endocrinology, Diabetes, and Metabolism
Lewis Katz School of Medicine at Temple University
Chair, Glycemic Control Taskforce, Temple University Hospital
Communications Director, Health Care Delivery & Quality Improvement Interest Group
------------------------------

Original Message------

Dear colleague,

I am writing to ask for your thoughts about whether there are any specific issues related to managing diabetes in hospitalized patients with COVID-19. Are you doing anything different from usual care (SC basal-bolus insulin for non-ICU and insulin drip for ICU patients)? Do you have experience and advice for managing COVID/DM patients on high-dose steroids?

Best regards,
Dan

------------------------------
Daniel J. Rubin, MD, MSc, FACE
Associate Professor of Medicine
Director of Clinical Research
Section of Endocrinology, Diabetes, and Metabolism
Lewis Katz School of Medicine at Temple University
Chair, Glycemic Control Taskforce, Temple University Hospital
Communications Director, Health Care Delivery & Quality Improvement Interest Group
------------------------------

We are interested in specifically management and risks of type 1 diabetes; this evening CET there will be a webinar ( in dutch) bij Medtronic:

Beste zorgverlener,   Na onze eerste zeer succesvolle webinar nodigen wij u nu graag uit voor de tweede webinar over diabetes type 1 en het COVID-19 virus op woensdag 1 april om 19.30 uur. Deze webinar is voor iedereen die geïnteresseerd is in diabetes type 1 en het COVID-19 virus.   Deze webinar zal in het teken staan van diabetes type 1 en ziekte. Welke handvatten kunt u als zorgverlener aan patiënten met diabetes type 1 geven en hoe zorgen we er voor dat de diabeteszorg in deze tijd gecontinueerd wordt.   Samen met de volgende organisaties: het Diabetesfonds, de JDRF en Diabeter hebben wij deze webinar voorbereid. Voor het beantwoorden van de vele vragen zullen naast de zorgverleners van Diabeter, M. Bizino internist uit het Groene Hart Ziekenhuis en I. Bosch physician assistant van de kinderkliniek Almere aan de webinar deelnemen.     Kijk voor meer details over de webinar op Facebook en stel een herinnering in.   Bekijk de webinar Datum: Woensdag 1 april Tijd: 19.30 uur   Tevens ontvangt u de link van de webinar van vorige week: de eerste aflevering 'Corona en diabetes type 1' van 25 maart     Met vriendelijke groeten,     Team Medtronic

​

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Bj potter van Loon
AMSTERDAM
------------------------------

Original Message:
Sent: 03-29-2020 22:12
From: Daniel Rubin
Subject: Diabetes management in COVID-19 patients

Dear colleague,

I am writing to ask for your thoughts about whether there are any specific issues related to managing diabetes in hospitalized patients with COVID-19. Are you doing anything different from usual care (SC basal-bolus insulin for non-ICU and insulin drip for ICU patients)? Do you have experience and advice for managing COVID/DM patients on high-dose steroids?

Best regards,
Dan

------------------------------
Daniel J. Rubin, MD, MSc, FACE
Associate Professor of Medicine
Director of Clinical Research
Section of Endocrinology, Diabetes, and Metabolism
Lewis Katz School of Medicine at Temple University
Chair, Glycemic Control Taskforce, Temple University Hospital
Communications Director, Health Care Delivery & Quality Improvement Interest Group
------------------------------

​Good afternoon, everybody.

Our hospital is preparing for a COVID surge in the coming weeks.  My CDE mentioned that some institutions that are currently inundated with patients are using glucometers that are not approved for inpatient use.  The goal of having a glucometer dedicated to each room that requires POC glucose monitoring seems reasonable.  It seems like we would be more likely to obtain outpatient glucometers than the inpatient devices on short notice.  Can anyone in an epicenter describe if this is current procedure?

I have read the suggestion for inpatient CGM.  This does not seem feasible at this point, and the data are not available regarding accuracy in ill patients.

Thank you!
Mark Wilson, MD
Santa Barbara

------------------------------
Mark Wilson BA, DMSC
SANTA BARBARA CA
------------------------------

Original Message:
Sent: 03-29-2020 22:12
From: Daniel Rubin
Subject: Diabetes management in COVID-19 patients

Dear colleague,

I am writing to ask for your thoughts about whether there are any specific issues related to managing diabetes in hospitalized patients with COVID-19. Are you doing anything different from usual care (SC basal-bolus insulin for non-ICU and insulin drip for ICU patients)? Do you have experience and advice for managing COVID/DM patients on high-dose steroids?

Best regards,
Dan

------------------------------
Daniel J. Rubin, MD, MSc, FACE
Associate Professor of Medicine
Director of Clinical Research
Section of Endocrinology, Diabetes, and Metabolism
Lewis Katz School of Medicine at Temple University
Chair, Glycemic Control Taskforce, Temple University Hospital
Communications Director, Health Care Delivery & Quality Improvement Interest Group
------------------------------

Helo  Mark,
I agree that any glucometer for in patient use is better than no glucometer, so if you can put your hands on out-patient equipment but not something approved for hospital use, then I would certainly recommend this approach.

As for CGM, I don't see why the accuracy of the sensor is dependent on the root cause of the glycemic level. The sensor only reacts to glucose molecules in the body. If the blood sugar level is high because of under dosing insulin, hormone increases after infection or any other reason, the sensor will still detect the glucose in the same way.  Having a CGM will make it much easier to provide intensive insulin therapy in order to reduce hyperglycemia and allow the body's normal defense mechanisms to operate more effectively.

Note that I am not a clinician, but an engineer in the Diabetes Tech industry.

Tom Bishop
CTO, PKvitality SAS

------------------------------
Tom Bishop
ECHO THERAPEUTICS
Danvers MA
------------------------------

Original Message:
Sent: 04-03-2020 16:38
From: Mark Wilson
Subject: Diabetes management in COVID-19 patients

​Good afternoon, everybody.

Our hospital is preparing for a COVID surge in the coming weeks.  My CDE mentioned that some institutions that are currently inundated with patients are using glucometers that are not approved for inpatient use.  The goal of having a glucometer dedicated to each room that requires POC glucose monitoring seems reasonable.  It seems like we would be more likely to obtain outpatient glucometers than the inpatient devices on short notice.  Can anyone in an epicenter describe if this is current procedure?

I have read the suggestion for inpatient CGM.  This does not seem feasible at this point, and the data are not available regarding accuracy in ill patients.

Thank you!
Mark Wilson, MD
Santa Barbara

------------------------------
Mark Wilson BA, DMSC
SANTA BARBARA CA

Original Message:
Sent: 03-29-2020 22:12
From: Daniel Rubin
Subject: Diabetes management in COVID-19 patients

Dear colleague,

I am writing to ask for your thoughts about whether there are any specific issues related to managing diabetes in hospitalized patients with COVID-19. Are you doing anything different from usual care (SC basal-bolus insulin for non-ICU and insulin drip for ICU patients)? Do you have experience and advice for managing COVID/DM patients on high-dose steroids?

Best regards,
Dan

------------------------------
Daniel J. Rubin, MD, MSc, FACE
Associate Professor of Medicine
Director of Clinical Research
Section of Endocrinology, Diabetes, and Metabolism
Lewis Katz School of Medicine at Temple University
Chair, Glycemic Control Taskforce, Temple University Hospital
Communications Director, Health Care Delivery & Quality Improvement Interest Group
------------------------------

Hi Dr. Wilson!

What a small world! Hope you and the Santa Barbara team are well as you prepare. You and the CDE that you work with have valid concerns, and CGM would be difficult to implement on a large scale at this point. Though hopefully your hospital policy does allow people with personal CGMs to continue using them while inpatient. That will be helpful at least, for patients that come in with their own.

We use glucometers approved for multi-patient use at our outpatient clinical research center. The ones we use are approved for both capillary and venous sampling. This may be really helpful in an inpatient setting, because you would have the ability to confirm any outlier readings with the same meter while waiting for an official reading to come back from the lab. I have been purchasing these meters for our facility, so feel free to message me if you want more information. Overall they have been affordable, and may be a good option for those patients that you have in isolation.

Sincerely,

Anna Barash RN CDE

------------------------------
Anna Barash RN BSN CDE
Clinical Research Nurse
Certified Diabetes Educator
Benaroya Research Institute
Seattle, WA

------------------------------

Original Message:
Sent: 04-03-2020 16:38
From: Mark Wilson
Subject: Diabetes management in COVID-19 patients

​Good afternoon, everybody.

Our hospital is preparing for a COVID surge in the coming weeks.  My CDE mentioned that some institutions that are currently inundated with patients are using glucometers that are not approved for inpatient use.  The goal of having a glucometer dedicated to each room that requires POC glucose monitoring seems reasonable.  It seems like we would be more likely to obtain outpatient glucometers than the inpatient devices on short notice.  Can anyone in an epicenter describe if this is current procedure?

I have read the suggestion for inpatient CGM.  This does not seem feasible at this point, and the data are not available regarding accuracy in ill patients.

Thank you!
Mark Wilson, MD
Santa Barbara

------------------------------
Mark Wilson BA, DMSC
SANTA BARBARA CA

Original Message:
Sent: 03-29-2020 22:12
From: Daniel Rubin
Subject: Diabetes management in COVID-19 patients

Dear colleague,

I am writing to ask for your thoughts about whether there are any specific issues related to managing diabetes in hospitalized patients with COVID-19. Are you doing anything different from usual care (SC basal-bolus insulin for non-ICU and insulin drip for ICU patients)? Do you have experience and advice for managing COVID/DM patients on high-dose steroids?

Best regards,
Dan

------------------------------
Daniel J. Rubin, MD, MSc, FACE
Associate Professor of Medicine
Director of Clinical Research
Section of Endocrinology, Diabetes, and Metabolism
Lewis Katz School of Medicine at Temple University
Chair, Glycemic Control Taskforce, Temple University Hospital
Communications Director, Health Care Delivery & Quality Improvement Interest Group
------------------------------