The prevalence of Diabetes Mellitus (DM), especially type 2 DM, is high in the general population in our environment, especially among those over 50 years of age. The coexistence of COVID-19 and DM can generate important complications and serious health problems.
Diabetics infected with SARS-CoV-2 have a higher rate of hospital admission, severe pneumonia and higher mortality compared to non-diabetic subjects.
The poor prognosis of the association of these two pathologies is due to the higher risk of infections in diabetic patients, determined by alterations in immunity that affect the function of macrophages and lymphocytes, without affecting humoral immunity (that mediated by immunoglobulins).
How should insulin doses be regulated?
SARS-CoV-2 virus enters cells through angiotensin-converting enzyme 2 (ACE2) membrane receptors, which are widely distributed in the lungs, intestines, heart, kidneys, endothelial cells and pancreas. Acute hyperglycemia increases ACE2 receptor expression, thereby facilitating viral entry into the cell. Chronic hyperglycemia causes cells to lose their protective mechanism and become more vulnerable to the virus and its proinflammatory effect.
In this way, COVID-19 can damage the pancreatic islets, where the pancreatic Beta cells, the insulin-producing cells, are located, which could worsen hyperglycemia and even induce the onset of diabetes in previously non-diabetic subjects. In addition, diabetes is associated with a chronic low-grade inflammatory state that can favor an exaggerated inflammatory response and, therefore, the appearance of acute respiratory distress syndrome. Therefore, diabetics are at greater risk of Covid-19 infection, worse prognosis and greater difficulty in glycemic control; and consequently, greater need for insulin.
In general, the dose of insulin administered will have to be increased. In addition, it will be necessary to increase this to a greater extent in hospitalized patients, especially those who are administered glucocorticoids, which have a clear hyperglycemic profile.
What other precautions should be taken?
1. In patients with DM not infected by COVID-19.
– Intensify their metabolic control (basal glycemia, glycosylated Hb) in order to prevent complications if they are infected by COVID-19.
– Make consultations with specialists in Internal Medicine through telemedicine or telephone consultations to reduce exposure during the pandemic.
– Avoid high HbA1c levels, especially in patients with DM1, since this weakens the immune system against any infection.
– Monitor and follow up glycemic controls to avoid decompensations such as diabetic ketoacidosis and detect patients at risk of hypoglycemia.
2. Regarding DM comorbidities.
– Arterial hypertension (AHT): it is recommended to continue with drugs called angiotensin converting enzyme inhibitors (ACE inhibitors).
– Dyslipidemia: it is recommended to continue treatment with statins, optimizing the objectives in terms of LDL levels (LDL levels must be below 100 mg/dl).
– Patients with DM and obesity are at an elevated risk of respiratory problems if infected with SARS-COV-2.
3. Non-pharmacological recommendations
– Follow healthy dietary habits.
– Maintain weight, regulating caloric needs at all times.
– Physical exercise is essential. Perform a minimum of 150 minutes a week, combining an aerobic part and muscular strength training.
4. Pharmacological recommendations
– Discontinue metformin in infected patients because of the possibility of lactic acidosis, a serious and potentially fatal complication related to this drug.
– Sodium-glucose cotransporter type 2 (ISGLT-2) inhibitors increase the risk of diabetic ketoacidosis and should be discontinued in case of COVID-19 infection.
– DPP-4 inhibitors are generally well tolerated during infection and can be maintained.
– Patients with glucagon-like peptide (GLP-1) agonists should be closely monitored, and care should be taken with hydration in patients treated with these drugs.
– Patients on insulin treatment should maintain their insulin levels, with strict control of blood glucose levels in the event of an increase in requirements that could lead us to suspect a clinical worsening of the infected patient.
According to a press release from the Novo Nordisk Diabetes Foundation, patients with hypertension and diabetes are at increased risk of neurological complications such as cerebral hemorrhages and strokes. Why is there a higher risk in diabetic patients?
The effects of COVID-19 reach far beyond the chest. Although brain complications are rare, they are an increasingly frequent and potentially devastating consequence of COVID-19 infection, especially in hypertensive and diabetic patients. These two pathologies are well known cardiovascular risk factors and by themselves can predispose to ischemic stroke; in addition, in the case of SARS-COV-2 infection, this virus has the capacity to activate coagulation, producing thrombotic phenomena in the central nervous system as well.
Until now, the neurological manifestations of COVID-19 were considered to be the result of direct damage to nerve cells. However, several studies from biopsies of deceased coronavirus patients indicate that the virus may damage the small blood vessels of the brain rather than the nerve cells themselves. Due to ACE2 receptors in the brain, it is suggested that SARS-CoV-2 spreads through the vascular endothelium, damaging it and causing platelet aggregation. In addition, the alteration of coagulation resulting from the “cytokine storm” through an inflammatory response alters both platelets and increases D-dimer and fibrinogen. Thus, inflammation and vascular damage occurs in these blood vessels, in the form of microthrombi both in the brainstem and olfactory bulb (the cause of olfactory loss), as well as in other brain areas. These lesions can give rise to ischemic phenomena (stroke, due to lack of irrigation of a certain area) or can even turn into hemorrhagic phenomena, which can logically produce cerebral hemorrhages, more frequent and probable in the case of uncontrolled arterial hypertension.
Another complication that can be associated with Covid-19 is cerebral venous thrombosis (CVT). CVT consists of the obstruction of the venous sinuses or cerebral veins by a thrombus. This results in increased intracranial pressure, the main symptoms of patients with CVT being subacute headache (90%), seizures (40%), neurological focality (50%) and, in some cases, coma (10%).
The described mechanism of this hypercoagulable state, together with the inflammatory response and prolonged immobilization of patients with COVID-19 may help to explain the formation of CVT. This clinical entity can occur in both older and younger patients and independently of the coexistence of cardiovascular risk factors such as diabetes and hypertension.
What other consequences for diabetics involve contracting COVID-19?
In the current pandemic situation, this can lead to a deterioration in the control of the disease in diabetics, mainly due to the lack of physical activity, increased stress associated with confinement, restricted mobility or fear of contracting the disease and, above all, due to the difficulty of access to the healthcare system.
It is therefore essential to facilitate this access through tools such as telemedicine to advise patients and caregivers on the adaptation of treatment and on any other clinical situation that can be managed remotely.