Diabetes and COVID-19

COVID-19, Diabetes and glycemic management

  • 1.  COVID-19, Diabetes and glycemic management

    Posted 04-05-2020 12:12

    We are concerned about how to manage glycemic control in patients with Coronavirus Disease 2019 (COVID-19). We just do not have the information -is there evidence that changes are needed? Are we doing too many POC-CGMs in COVID-19 individuals, and or others? Can the outcomes be different if we decrease the intensity of glucose monitoring in intubated critically ill individuals with COVID-19? Nobody has the answer, but it is an opportunity to reflect, get data, and make the needed changes. 

    It is unimaginable and sad that we know so little about the Wuhan Novel Coronavirus (2019-nCoV) and COVID-19. This is after almost four months of an epidemic, now a pandemic, as declared officially by the World Health Organization (WHO) on March 11, 2020, after weeks of hesitation. It is a disease that we can't prevent as we have no vaccine. Prevention, therefore, has been based by isolation derived from, observations of the bubonic plague during three long years (1347–1350), and from more recent viral infections such as the Spanish Flu pandemic in 1918, SARS, MERS, and the Swine Flu. COVID-19 is highly contagious but we do not have accurate information on how it is transmitted and we still do not have readily available tests for screening.  Prevention by isolation is effective when done early in the disease, and when the confined cases are few or from a single and or small dwelling. Isolation worked well centuries ago before changes in society, technology, and heavy traveling flux. Since the majority of individuals with COVID-19 can be contagious but not sick, isolation needs to be absolute and early in the epidemic. Undoubtedly isolation is helping –but how much is another question for which we need data. We are using circular reasoning, a logical fallacy where fewer cases are attributed to better or earlier isolation, a circular argument logically valid because if the premises are true, the conclusion must be true. Is the type of isolation taking place too much too late?  We need data rather than stating that there are more or fewer cases because isolation was not done or done better.

    We have no proven treatment and unfortunately, mortality is high. It is precipitated by hypoxemia caused by acute respiratory distress syndrome (ARDS) in the majority. Individuals with ARDS have a poor prognosis even when ventilator management strategies are available. Data from Europe shows a 70% mortality in intubated patients with COVID-19; this may be even higher in the US; data is being collected and should be published soon. Effective control of infectious diseases in this century requires effective public health infrastructures that can rapidly recognize and respond. In summary, we now have a crisis created by politics, inertia, and incompetence. There is no real prevention or treatment, the lack of real data information has resulted in flip-flopping, and often late recommendations, resulting in a potential economic collapse.

    The case fatality rate (CFR, number of deaths/number of those diagnosed) differs with reports from China suggested initially a CFR of 2.3% that was lowered to 1.4%. It contrasts with influenza (0.1%), MERS (34%), and SARS (10%). Based on reported data from March 21st, 2020, COVID-19 CFR varies significantly by country: China 4.0% (81,304 cases), Italy 8.6% (47,021 cases), Iran 7.5% (20,610 cases), Spain 5.4% (25,374 cases), South Korea 1.2% (8,779 cases), Germany 0.3% (21,828 cases), and the United States 1.3% (22,043 cases), so far. As expected, the CFR rises with increasing age and comorbidities, and it is 10.5% for cardiovascular disease; 7.3% for diabetes mellitus; 6.3% for COPD; 6% for HTN; and 5.6% for cancer.

    I have been searching for "real data" expecting plenty of information months after the disease was identified, but most of the published literature is opinion-driven without data. Information from China should be available by now. The Wu Z and McGoogan JM, Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. Feb 24, 2020, provides data from 72,314 COVID19 cases, 44 672 (62%), confirmed by using positive reverse transcription-polymerase chain reaction (rRT-PCR) from nasopharyngeal swab (accuracy of the test used not known), and 16,186 (22%) diagnosed clinically (per symptoms and or exposure). The majority (87%) were between 30 to 79 years old, and only 3% were age 80 years or older. There is no data regarding diabetes type, duration of the disease, medications used, A1c or glycemic control, cardiovascular disease, and or management. It is stated that 7.3% of cases had diabetes, an amount that may be similar or lower than the general population. The excellent recent Circulation article, on the current knowledge base for COVID-19 and myocardial injury/cardiovascular disease ww.ahajournals.org/doi/10.1161/..., diabetes is cited as a risk, with a 7.3% prevalence, again without other data. Obesity and diabetes were thrown, almost with a knee-jerk reflex, as major risk factors but without "real data".

    The best information available comes from the recently published CDC report, Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 - United States, February 12–March 28, 2020. Weekly / April 3, 2020 / 69(13);382–386, posted online. As of March 28, 2020, in the U.S. states and territories, 122,653 U.S. of COVID-19 cases were reported to the CDC, of those, 7,162 (5.8%) had underlying health conditions and more likely to have ICU admission. The most commonly reported conditions were diabetes mellitus, chronic lung disease, and cardiovascular disease. It is not yet known whether the severity or level of control of underlying health conditions affects the risk for severe disease. Many of these underlying health conditions are common, with a prevalence of diabetes of 10.1%, and age-adjusted prevalence of all types of heart disease (excluding hypertension without or other heart disease) of 10.6%.  From 74,439 (60.7%) case report forms submitted to CDC, diabetes mellitus was present in 784, 10.9%. Since diabetes is closely associated with cardiovascular disease, it is unclear how many had cardiovascular disease. Individuals with diabetes do not appear to be more susceptible to acquire severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), but are at an increased rate of morbidity and mortality for COVID-19, stressing the need for prevention.

    Appropriate glycemic control is vital in all, and not only in those infected and or affected by COVID-19. We need "real data" not only of glycemic control and lipid profiles but also of cardiovascular disease in individuals with diabetes, in order to obtain a proper evaluation and execute the right treatment. This is an opportunity to reset the way we treat our patients with diabetes.  An effective, low intensity and less expensive regimen need to be formulated for the management of hyperglycemia in hospitalized patients.

    Joel Zonszein, MD, FACP, FACE
    Emeritus Professor of Medicine, Albert Einstein College of Medicine
    The Fleischer Institute for Diabetes and Metabolism
    Department of Medicine, Division of Endocrinology and Metabolism
    Montefiore Medical Center
    The University Hospital for Albert Einstein College of Medicine
    1180 Morris Park Avenue, Bronx, NY  10461
    Phone: 347 498-2445, Fax: 718 239-8285
    Emails: jzonszei@montefiore.org  joel.zonszein@einstein.yu.edu