Expert panel offers practical recommendations for diabetes management during coronavirus pandemic

Representatives from primary and secondary care have developed a consensus document on the management of diabetes in people at risk of or with confirmed COVID-19, including advice on stopping certain antidiabetic drugs.

Optimal glycaemic control is important in patients with diabetes to reduce the risk of severe COVID-19. | GETTY IMAGES
Optimal glycaemic control is important in patients with diabetes to reduce the risk of severe COVID-19. | GETTY IMAGES

The panel of experts, whose recommendations are published in The Lancet Diabetes and Endocrinology, emphasise the advice is based on expert opinion in the absence of data from randomised clinical trials.

They say optimal management of diabetes is important as global epidemiological data shows the incidence and severity of COVID-19 infection is increased in people with diabetes. They highlight that people with comorbid conditions, such as fatty liver disease or obesity, are likely to have particularly high risk of severe COVID-19 infection.

The guidance calls for 'high-grade' protection for healthcare workers with diabetes who remain on front-line duties.

Metabolic control

The panel says patients who have not yet been infected with the SARS-CoV-2 virus should intensify their metabolic control to reduce the risk of infection. This includes control of blood pressure and lipids as well as glycaemia. Consistent with recent guidance from European and US cardiology societies, the panel recommends continuing antihypertensive regimens including ACE inhibitors and angiotensin receptor blockers. Statin treatment should also be continued, they say.

People with type I diabetes are particularly susceptible to infections and require more intense monitoring and supportive therapy to reduce the risk of metabolic decompensation. The panel says it is 'crucial' to remind these patients about typical symptoms of diabetic ketoacidosis, home-measurement of urine or blood ketones, acute behaviour guidelines, the need to seek medical advice promptly and sick day rules.

Discontinuing medicines

The panel recommends metformin and SGLT2 inhibitors be discontinued in patients with severe symptoms of COVID-19 to reduce the risk of lactic acidosis and diabetic ketoacidosis respectively, although these adverse effects are rare. Patients should follow sick-day rules and renal function should be carefully monitored.

If drugs are discontinued, the alternative treatment of choice (if feasible) is insulin.

Discontinuing SGLT2 inhibitors and metformin is not recommended prophylactically for non-hospitalised patients with diabetes who do not have any symptoms of severe COVID-19 infection.

GLP-1 agonists can be continued but patients should be advised to maintain sufficient fluid intake as dehydration is likely to lead to severe illness. The panel say there is 'no convincing evidence' to suggest that DPP4 inhibitors should be discontinued.

Insulin must not be stopped and patients using insulin should be encouraged to monitor blood glucose every 2—4 hours or use continuous monitoring.

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