COVID-19 and Diabetes Mellitus – A Bad Marriage

Dr Jaime Davidson is a Clinical Professor of Internal Medicine at the University of Texas Southwestern Medical Center, Touchstone Diabetes Research Center and a member of the executive committee on CME. He is the Past President of the Worldwide Initiative for Diabetes Education, a non-for-profit international diabetes foundation. He serves in the Diabetes task force of the National Minority Quality Forum and was a member of the advisory board for the FDA Endocrinology, Diabetes and Metabolic Diseases for a six-year period. He has served as Chair of the Texas Diabetes Council and the Texas Department of Health Services. Dr. Davidson is a member of the Endocrine Society (ESE), a lifetime member of the International Diabetes Federation (IDF) and a charter member in the formation of the American Association of Clinical Endocrinologists (AACE). He chaired the AACE Diabetes Guidelines in 2001 and the initial road map for the prevention and treatment of Type 2 Diabetes.

 

Diabetes mellitus is a chronic disease that affects 34.2 million Americans: 26.8 million diagnosed and 7.3 million undiagnosed.¹ In addition, almost 88 million Americans have prediabetes.¹ The global diabetes prevalence in 2019 was estimated to be 9.3% with an estimated 463 million people affected with the condition.² Diabetes qualifies as a global epidemic, and by 2030, is expected to reach 10.2% prevalence and affect more than 575 million people.²

COVID-19 belongs to a family of viruses, Coronaviridae, officially named SARS-CoV-2. Previous viruses to have caused severe disease in humans, have been SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome). From the same family of viruses, HKU1, NL63 and OC43 are known to typically cause just mild symptoms.

The pandemic recently declared by the World Health Organization was due to the rapid spread of the newest virus, COVID-19, from China to the rest of the world: Asia, Europe, North America, South America, Africa, Oceania and the Middle East. To date (30 March 2020), Italy is the hardest hit, with 10,779  deaths; the most for a single country, and spreading to the rest of Europe with significant new cases in Spain, France, Germany, etc.³ In the United States, the most cases reported are in New York, New Jersey, Washington and California. The total number reported as of 29 March 2020 in New York, is 59,568 and 965 deaths, with a US total of 141,995 cases and 2,486 deaths.⁴

Since COVID-19 has an identical genome to coronavirus found in bats, and the original outbreak was in Wuhan, China, a region where bats are consumed, this appears to be the best explanation for the outbreak.⁵ There are numerous other theories as to the origins of the virus; however, the important thing is to realise that it is spreading quickly, it is highly contagious and that there is no known treatment or immunisation. Scientists throughout the world are working to find treatments and vaccines. It’s critical to stay on top of developments and educate patients affected by the combination of a chronic disease (epidemic) such as diabetes and an acute viral infection like COVID-19 (pandemic) in order to save lives, decrease human suffering and reduce the cost of care.

Patients with diabetes are considered high-risk patients for acquired infections, and among the risk factors is ambient glucose. The higher the glucose, the higher the risk of infections.⁶ The vast majority of patients in the United States are not reaching glucose goals (70%).⁷ In addition, most patients with diabetes, develop over time, co-morbidities that increase such risks.

Symptoms

People may be infected with the virus from 1–14 days without symptoms. The most common symptoms are fever, tiredness and dry cough, and there has also been a report from the United Kingdom that anosmia, a loss of smell and therefore taste, can be a symptom.⁸ Other symptoms include headache and the most severe complication is difficulty breathing when the virus affects the lungs by causing significant inflammation.⁹ Reports from China showed this complication to be most common in the elderly, smokers, and people with chronic conditions.^10,11 However, in contrast, emerging evidence has reported that smoking may not be associated with disease severity.^12,13 There is also an apparent gender imbalance with a greater number of COVID-19 deaths reported in men.^13,14

Diagnosis

We cannot recommend testing every individual with mild symptoms, as the resources simply do not exist; moreover, it would not be cost-effective. Age and good medical history will help us decide who should be tested in order to take the proper steps. At the present time, the most readily available tests are not timely; it takes more than 24 hours to get results. The Centers for Disease Control and Prevention recommends collecting and testing upper respiratory tract specimens (nasopharyngeal swab),¹⁴ contact the local healthcare department for updates and notify them of any patient where the suspicion of COVID-19 exists. Mobile units with drive-through are now operating in several US cities. Due to the number pre-screening may be required in order to accommodate those at high risk.  Either by temperature screening or questionnaire.¹⁵

Some faster diagnostic tests have been approved and others are currently being reviewed for approval. These tests should help us make earlier, swifter and more-effective decisions. On 27 March 2020, Abbott announced that the FDA has issued an Emergency Use Authorization (EUA) for the Abbott ID NOW™ COVID-19 test. This is a newly developed molecular point-of-care test for the detection of COVID-19 in the US, delivering positive results in 5 minutes and negative results in 13 minutes. Abbott hopes to produce approximately 5 million tests per month. ¹⁶

This test allows us to decide who needs treatment based on immediate results plus the clinical picture (fever, dry cough, shortness of breath, fatigue, etc). This enables triage as follows: i) who is infected and needs medical help; ii) who has overcome the virus, is no longer contagious and is able to go back to work and become productive immediately. For safety purposes, in this instance, the nasopharyngeal swab should be negative. Family members exposed, may be infected and we must recommend application of all the preventive measures.

Radiography findings

Hallmarks on imaging are bilateral and peripheral ground-glass and consolidative pulmonary opacities. An important percentage of patients may have symptoms but not display radiographic changes. If the condition worsens, repeating these studies is a must.

Treatment

There is no treatment for the condition. There is, however, a small trial reported from France using hydroxychloroquine and azithromycin with good results in patients with respiratory symptoms.¹⁷ The endpoint of the study was based on a negative test (i.e., absence of the virus) after treatment, and not on the health status of the participating individuals. In addition, the National Institute of Allergy and Infectious Diseases is currently undertaking a clinical trial with remdesivir vs placebo for the treatment of COVID-19 (ClinicalTrials.gov identifier NCT: NCT04280705).¹⁸ This trial is still in progress; however, because of the short duration of the intervention, findings should become available in a reasonable time.

Prevention

Prevention is the best way to solve a rapidly-spreading illness. As this is communicable disease, the following recommendations should help to mitigate the spread of disease:

1. Maintain at least 2 metres distance from those who do not live in your household.

2. Clean your hands often, especially when returning from a public place and after blowing your nose, sneezing or coughing. Use disposable tissues and discard them immediately.

3. Avoid touching your eyes, nose and mouth, especially with unwashed hands.

4. The most effective way to clean your hands is with soap and warm water for at least 20 seconds and all around your hands. Be sure your nails are clean.

5. Keep oral mucosa wet. Drink water frequently and lozenges may be helpful.

6. Don’t share cell phones or tablets and ensure your own devices are clean.

7. If you are in a community where social restrictions exist, there is a good reason for this, and healthcare professionals should help educate the public regarding why those restrictions are in place.

8. If an individual in a workplace is diagnosed with the virus, all people that were in contact should enter into a period of quarantine but do not need to be tested.

Summary

The combination of a medical pandemic (COVID-19) with a medical epidemic (diabetes mellitus) is very concerning. Treating diabetes to ensure the patient stays within target ranges, keeping patients well hydrated and following the recommendations to prevent infection with the coronavirus is essential to prevent a more devastating picture in patients with a chronic condition such as diabetes.

 

References

Data in this article were accurate a time of writing (3 April 2020). Please be aware that the information in several of these references is being updated regularly, and therefore may no longer reflect the figures reported in this article.

1. American Diabetes Association. Statistics About Diabetes. Available at: www.diabetes.org/resources/statistics/statistics-about-diabetes (accessed 30 March 2020).
2. International Diabetes Federation. IDF Diabetes Atlas 9^th edition 2019. Available at: www.diabetesatlas.org/en/resources/ (accessed 30 March 2020).
3. Worldometer. COVID-19 Coronavirus Pandemic. 2020. Available at: www.worldometers.info/coronavirus/ (accessed 30 March 2020).
4. The New York Times. The Coronavirus Outbreak. 2020. Available at: www.nytimes.com/news-event/coronavirus (accessed 30 March 2020).
5. Guo YR, Cao QD, Hong ZS, et al. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak – an update on the status. Mil Med Res. 2020;7:11.
6. Casqueiro J, Casqueiro J, Alves C. Infections in patients with diabetes mellitus: A review of pathogenesis. Indian J Endocrinol Metab. 2012;16(Suppl1):S27–S36.
7. Iglay K, Hannachi H, Howie PJ, et al. Prevalence and co-prevalence of comorbidities among patients with type 2 diabetes mellitus. Curr Med Res Opin. 2016;32:1243–52.
8. ENT UK. Loss of sense of smell as marker of COVID-19 infection. Available at: www.entuk.org/sites/default/files/files/Loss%20of%20sense%20of%20smell%20as%20marker%20of%20COVID.pdf (accessed 30 March 2020).
9. Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. J Autoimmun. 2020: 102433. doi: 10.1016/j.jaut.2020.102433. [Epub ahead of print].
10. Liu W, Tao ZW, Lei W, et al. Analysis of factors associated with disease outcomes in hospitalized patients with 2019 novel coronavirus disease. Chin Med J (Engl). 2020: doi: 10.1097/CM9.0000000000000775. [Epub ahead of print].
11. Vardavas CI, Nikitara K. COVID-19 and smoking: A systematic review of the evidence. Tob Induc Dis. 2020;18:20.
12. Lippi G, Henry BM. Active smoking is not associated with severity of coronavirus disease 2019 (COVID-19). Eur J Intern Med. 2020: pii: S0953-6205(20)30110-2. doi: 10.1016/j.ejim.2020.03.014. [Epub ahead of print].
13. Cai H. Sex difference and smoking predisposition in patients with COVID-19. Lancet Respir Med. 2020: pii: S2213-2600(20)30117-X. doi: 10.1016/S2213-2600(20)30117-X. [Epub ahead of print].
14. The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. Vital Surveillances: The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020. China CDC Weekly. 2020;2:113–22.
15. Centers for Disease Control and Prevention. Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19). 2020. Available at: www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html (accessed 30 March 2020).
16. Press release. Abbott launches molecular point-of-care test to detect novel coronavirus in as little as five minutes. Available at: https://abbott.mediaroom.com/2020-03-27-Abbott-Launches-Molecular-Point-of-Care-Test-to-Detect-Novel-Coronavirus-in-as-Little-as-Five-Minutes (Accessed: 31 March 2020)
17. Gautret P, Lagier JC, Parola P, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. 2020: 105949. doi: 10.1016/j.ijantimicag.2020.105949. [Epub ahead of print].
18. ClinicalTrials.gov. Adaptive COVID-19 Treatment Trial (ACTT). Available at: https://clinicaltrials.gov/ct2/show/NCT04280705 (accessed 30 March 2020).

 

Support: Commissioned, edited and funded by Touch Medical Media

Published: 3 April 2020