Dr Angela Murphy updates on us on the current research on COVID-19 and diabetes.
People living with diabetes have been particularly concerned during this COVID-19 pandemic as they are described as a ‘high-risk or vulnerable’ population.
The volume of information being broadcast is unprecedented and it can be difficult to sift through the facts. Now at the start of winter and facing the probable COVID-19 peak in South Africa, it is a good time to assess what we truly know about COVID-19.
What is COVID-19?
COVID-19, corona virus disease-19 (because it was first described in December 2019), was first reported in China but soon spread around the world and officially started in South Africa in March 2020.
The corona virus can incubate for two-14 days and many patients will remain asymptomatic throughout their infection. Others present with fever, cough, headache, fatigue, shortness of breath, loss of smell and a variety of less common complaints. Most people will not need hospitalisation; in fact, less than 15% of people have serious complaints. The question is who is at risk of the latter?
Why are diabetes patients grouped as high risk?
Having diabetes does not increase the likelihood of contracting COVID-19. However, diabetes, along with hypertension, obesity, lung and kidney disease and chronic heart disease, has been associated with a more severe disease.
Older people with Type 2 diabetes are more susceptible to infections, such as influenza and pneumonia. Chronically raised blood glucose levels suppress the immune system and allow invading viruses and bacteria to multiply, including the new corona virus.
Conversely, having an infection causes a stress response from the body which can further increase glucose levels and exacerbate the infection. It is quite clear that good control of diabetes can mitigate this cycle. If COVID-19 is contracted, it is also important to aim for good blood glucose levels while ill.
Doctors treating COVID-19 around the world have observed that patients become particularly resistant to insulin during the course of their disease. It is thought that COVID-19 may cause direct damage to the insulin secreting beta-cells of the pancreas. This means some patients may require insulin for the first time while others need to increase their insulin doses significantly. Vigilant monitoring of blood glucose is essential.
Another concerning observation is the severe inflammation that is seen in COVID-19. This causes tissue damage throughout the body, not only the lungs. It also increases clotting of blood and damages blood vessels which are already compromised with underlying diabetes and hypertension. All of which is the reason some people become very ill.
There does now seem to be evidence that the level of glucose control impacts on the course of COVID-19 disease. Data from the United Kingdom showed that as base line HbA1c increased above 7,5%, there was an increase in more severe COVID-19.
In addition, patients with a body mass index (BMI) of >40kg/m2 – which classifies them as severely obese – also had more serious outcomes. Studies from New York City in the United States of America revealed that 40% of patients admitted for COVID-19 were obese (BMI>30kg/m2).
It is a stressful time and information like this can lead to more stress. We should rather use this as an opportunity to improve the lives of people living with chronic metabolic conditions of diabetes, hypertension, and obesity.
Now, more than ever, we will see a return in the investment of healthy living. A balanced diet high in fresh produce and low in processed foods is key. Regular physical activity will improve weight loss, insulin resistance and psychological well-being.
Managing diabetes and COVID-19
Although several drugs are being used to treat COVID-19, there is no accepted cure for the virus at present. There are recommendations of how to manage diabetes in the event of getting infected with COVID-19, especially where hospitalisation is not needed. An international panel of diabetes experts published guidelines in The Lancet journal in April 2020.
For patients with diabetes who develop COVID-19, most will have a mild infection. However, it is important to review the chronic prescription and go through sick day management. Paracetamol is recommended for fever and body aches and it is extremely important to have a good fluid intake.
Some diabetic medications may increase the risk of dehydration and acidosis (increased acidity in the blood and other body tissues) and will need to be stopped temporarily.
Patients on insulin may have to increase their doses during times of fever. It is critical that patients communicate with their diabetes care team (doctor and diabetic nurse educator) if they have COVID-19 so that individual advice can be offered.
Many practices are using Telehealth consultations; this may be as simple as a phone call or a video platform, such as Zoom. Most patients, even with the higher risk co-morbidities, will be able to recover from home.
Other measures that are being recommended include being up to date with the annual flu vaccine and the pneumococcal vaccine as recommended by the National Institute of Communicable Diseases. Although, neither of these can prevent being infected with COVID-19. They will protect from other common respiratory illnesses. Less illnesses mean less visits to doctors’ rooms where risk of exposure is higher.
Social distancing and hygiene still imperative
Several drugs to effectively treat COVID-19 are under investigation. However, prevention of infection, especially in high-risk groups of people, remains a vital strategy. The evidence strongly advocates social distancing and hygiene.
A study published, in The Lancet, reported that when people kept a metre or more apart, the chance of infection or transmission dropped from 12,8% to 2,8%. Wearing masks or respirators decreased transmission from 17,4% to 3,1%. Adding strict cleaning of surfaces further reduces the risk.
COVID-19 has changed our world and created hardship for many. We need to turn this into a challenge to improve the way we live and work and manage our health. I strongly encourage all people with chronic medical conditions to keep all their scheduled check-ups at this time, even if it done as a virtual consultation. Stay informed, stay home and stay well.
www.thelancet.com/diabetes-endocrinology– Practical recommendations for the management of diabetes in patients with COVID-19. Borntein F R, et al. April 23, 2020
MEET THE EXPERT
Dr Angela Murphy is a specialist physician working in the field of Diabetes and Endocrinology in Boksburg. She is part of the Netcare Sunward Park Bariatric Centre of Excellence and has a busy diabetes practice.