For sick patients
Guidelines for patients at the Joslin Diabetes Center in Boston advise patients who are feeling sick to continue taking their diabetes medications, unless instructed otherwise by their providers, and to monitor their glucose more frequently because it can spike suddenly.
Patients with type 1 diabetes should check for ketones if their glucose passes 250 mg/dL, according to the guidelines, and patients should remain hydrated at all times and get plenty of rest.
“Sick-day guidelines definitely apply, but patients should be advised to get tested if they have any symptoms they are concerned about,” said Dr. Rettinger, of the Endocrinology Medical Group of Orange County, Orange, Calif.
If patients with diabetes develop COVID-19, then home management may still be possible, according to Ritesh Gupta, MD, of Fortis C-DOC Hospital, New Delhi, and colleagues (Diabetes Metab Syndr. 2020 Mar 10;14:211-2. doi: 10.1016/j.dsx.2020.03.002).
Dr. Rettinger agreed, noting that home management would be feasible as long as “everything is going well, that is, the patient is not experiencing respiratory problems or difficulties in controlling glucose levels. Consider patients with type 1 diabetes who have COVID-19 as you would a nursing home patient – ever vigilant.”
Dr. Gupta and coauthors also recommended basic treatment measures such as maintaining hydration and managing symptoms with acetaminophen and steam inhalation, and home isolation for 14 days or until the symptoms resolve. However, the ADA warns in its guidelines that patients should “be aware that some constant glucose monitoring sensors (Dexcom G5, Medtronic Enlite, and Guardian) are impacted by acetaminophen (Tylenol), and that patients should check with finger sticks to ensure accuracy [if they are taking acetaminophen].”
In the event of hyperglycemia with fever in patients with type 1 diabetes, blood glucose and urinary ketones should be monitored often, the authors wrote, cautioning that “frequent changes in dosage and correctional bolus may be required to maintain normoglycemia.” Dr Rettinger emphasized that “hyperglycemia, as always, is best treated with fluids and insulin and frequent checks of sugars to be sure the treatment regimen is successful.”
In regard to diabetic drug regimens, patients with type 1 or 2 disease should continue on their current medications, advised Yehuda Handelsman, MD. “Some, especially those on insulin, may require more of it. And the patient should increase fluid intake to prevent fluid depletion. We do not reduce antihyperglycemic medication to preserve fluids.
“As for hypoglycemia, we always aim for less to no hypoglycemia,” he continued. “Monitoring glucose and appropriate dosage is the way to go. In other words, do not reduce medications in sick patients who typically need more medication.”
Dr. Handelsman, medical director and principal investigator at Metabolic Institute of America, Tarzana, Calif., added that very sick patients who are hospitalized should be managed with insulin and that oral agents – particularly metformin and sodium-glucose transporter 2 inhibitors – should be stopped.
“Once the patient has recovered and stabilized, you can return to the prior regimen, and, even if the patient is still in hospital, noninsulin therapy can be reintroduced,” he said.
“This is standard procedure in very sick patients, especially those in critical care. Metformin may raise lactic acid levels, and the SGLT2 inhibitors cause volume contraction, fat metabolism, and acidosis,” he explained. “We also stop the glucagon-like peptide receptor–1 analogues, which can cause nausea and vomiting, and pioglitazone because it causes fluid overload.
“Only insulin can be used for acutely sick patients – those with sepsis, for example. The same would apply if they have severe breathing disorders, and definitely, if they are on a ventilator. This is also the time we stop aromatase inhibitor orals and we use insulin.”