COVID-19 research briefing 29/04/20 – diabetes

woman doing blood sugar test

Researchers from across BHP are collaborating to analyse and summarise the latest COVID-19 literature to help inform clinical colleagues. Today’s update focuses on patients with diabetes – 20-30% of coronavirus patients at University Hospitals Birmingham have diabetes, and they are likely to have increased severity of the virus. This infographic summarises practical adjustments to standard diabetes care, in patients hospitalised with COVID-19.

 

Admissions advice

CHECK:

      • Blood glucose levels in ALL patients
      • Capillary ketones in patients where diabetes is known – levels of 1.5 to 2.9 mmol/L give an increased risk of diabetic ketoacidosis (DKA)
      • Capillary ketones in ANY patient if their blood glucose is > 15 mmol/L

STOP:

      • SGLT-inhibitor therapy – it can cause euglycaemic DKA
      • Metformin, if the patient is dehydrated, has raised actate or acute kidney injury

(Note – never stop background insulin in patients with either Type 1 or Type 2 diabetes mellitus). 

NOTES:

Examine the feet of all patients with diabetes – in particular for acute ulceration, infection or ischaemia. 

Atypical presentations including euglycaemic DKA can occur spontaneously in coronavirus patients, and manifests as profound ketosis (ketones > 3.0 mmol/L) and acidosis (pH < 7.3) at normal blood glucose levels. 

Treat euglycaemic DKA, DKA and hyperosmolar hyperglycaemic state (HHS) as per your Trust guidelines, but give IV fluid at half the normal rate if COVID19 is present or suspected, due to significant acute lung and cardiac problems. 

Ward advice
      • Encourage patient self-management where possible
      • Glucose target of 5-15 mmol/L
      • Check capillary ketones in all patients with blood glucose levels of > 15 mmol/L, or if patient is unwell with a normal blood glucose level
      • Limit the use of VRIII (insulin sliding scale)
      • If insulin pump patients are not able to self-manage, start s/c basal insulin regimen and remove pump (after s/c insulin administered)
      • Continuous glucose monitors can be left on, but require conventional capillary glucose monitoring as well
      • Pumps and monitors can be used for non-magnetic imaging (X ray or CT scan) but not magnetic imaging procedures (MRI)
Critical care advice

Ventilated patients are highly insulin-resistant and require high rates of infusion – > 20 U/hr. 

In patients nursed prone, there is a paradoxical risk of hypoglycaemia

Patients on SGLT-2 inhibitor therapy are at risk of spontaneous euglycaemic DKA. Check the capillary ketones of ANY patient with blood glucose of > 15 mmol/L or with unexplained metabolic acidosis. 

VRIII can be avoided in some patients due to the expected limitations in availability of infusion pumps. Consider reverting to s/c insulin – as per Trust guidelines – and make an early referral to the diabetes team.

Medication advice

Staff managing COVID-19 inpatients with diabetes are advised to temporarily stop the following medications, remembering the acronym DAMN GlucoSe drugs:

      • D – Diuretics
      • A – ACE inhibitors
      • M – Metformin
      • N – NSAIDs
      • G – GLP1 analogues
      • S – SGLT inhibitors

Download this advice for managing patients with COVID19 and diabetes as a pdf