Professional Documents
Culture Documents
OUTLINE
Countries,
Confirmed Confirmed Recovered/ areas or
cases Deaths Discharged territories with
cases
Cardiovascular Respiratory
Hypertension Diabetes diseases system disease
17±7 8±6 5±4 2±0
(95% CI 14-22%) (95% CI 6-11%) (95% CI 4-7%) (95% CI 1-3%)
OUTLINE
• People with diabetes are NOT MORE likely to get COVID-19 than the general population
• Diabetes is one of the high risk groups for developing severe illness from COVID-19
• The risk of having worse outcomes is similar for people with T1D and T2D
diabetes1
• Coronavirus likely to activate TLR3 and
Promotes
TLR4, leading to IL-6-dominated cytokine Diabetes
storms2,3
• IL-6 associated with death of COVID-19
patients4
1. Reza F, et al. Cytokine ,2019, 125 (2020) 154832 3. Allison L. T, et al. mBio, 2015 , 3:e00638-15
2. Travis B. ,et al. mBio, 2017 8:e00818-17. 4. Zhou F , et al. The Lancet 2020 March 9 online
Factors leading to high morbidity and mortality of COVID-19
in patients with type 2 diabetes
CVD Dyslipidemia AGE
BP Type 2 Diabetes IR
Hyper immune
response ACE2
SARS
Severity of COVID-19 CoV2
Rajpal A,. Journal of diabetes. 2020 Jul 16.
VICIOUS CYCLE BETWEEN DIABETES AND
COVID-19
Viral infections could
Patients with T2DM have induce diabetes, and lead
an increased grade of to fluctuations in blood
severity to SARS-CoV-2 glucose in diabetic patients,
due to immune dysfunction. which adversely influence
prognosis.
1. Timely blood glucose management for the outbreak of 2019 novel coronavirus disease (COVID-19) is urgently needed, Wang A, Diabetes Research & Clinical Practice :162(2020)108118
2. COVID-19: consider cytokine storm syndromes and immunosuppression, Mehta P et al. The Lancet, CORRESPONDENCE| VOLUME 395, ISSUE 10229, P1033-1034, MARCH 28, 2020
3. Expert Recommendation on Glucose Management Strategies of Diabetes Combine with COVID-19. J Clin Intern Med. 2020 Mar;37(3):215-219
4. https://www.touchendocrinology.com/insight/covid-19-infection-in-people-with-diabetes/ as accessed on 9th April, 2020
COVID-19 MAY ACCENTUATE DIABETES: POTENTIAL MECHANISM
System
Angiotensin ACE
(1-7)
Angiotensin
II ARBs
16
Well Controlled
Glycemic Good
Prognostic
Recommendations for COVID-19 Prevention in Diabetes Patients Endorsed by Chinese Diabetes Society (CDS).
CDS website: www.diab.net.cn CDS WeChat: CDS-TNB
DIABETES PROMOTES SEVERE PROGRESSION IN COVID-19
PATIENTS
• The presence of coexisting diabetes was more common among COVID-19 patients with severe disease than among those
with non-severe disease (16.2% vs.5.7%).*1
• Another nationwide analysis of comorbidity and its impact on 1,590 patients with COVID-19 in China also revealed that,
(22.9% vs 6.8%)2
The risk of reaching to the composite endpoints*
COVID-19 patients with comorbidities1 and disease severity among patients with COVID-192
P<0.001
45%
With chronic
P<0.001 Composite
Proportion of patients(%)
*Data was extracted regarding 1099 patients with laboratory-confirmed Covid-19 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in China through January 29th, 2020.
6%
8%
P<0.001 4%
4% 3,1% 2,3%
2,5%
2% 0,9%
0% 0%
All patients Diabetic Non- diabetic All patients Diabetic No comorbid
conditions*
N=1590 N=130 N=1460
N=20,982 N=1,102 N=15,536
* The comorbid condition variable, only includes a total of 20,812 patients and 504 deaths and these values were used to calculate percentages in the confirmed cases and
deaths columns.
**The Joint Mission acknowledges the known challenges and biases of reporting crude CFR early in an epidemic.
1. Zhang BC, et al. medRxiv preprint , 2020 online 3.China CDC Weekly,2020, 2(8): 113-122
2. Guan WJ,et al. medRxiv preprint , 2020 online 4.《Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19),2020
ASSOCIATIONS OF DIABETES AND FBG WITH FATALITY
OF COVID-19
procalcitonin).
tanpa RIK 1 & 3),
FBG, fasting blood glucose unpublished data
Zhang Y et al. https://www.medrxiv.org/content/10.1101/2020.03.24.20042358v1
PowerPoint Presentation Date 22
Zhu, L., She, Z.G., Cheng, X., Qin, J.J., Zhang, X.J., Cai, J., Lei, F., Wang, H., Xie, J., Wang, W. and Li, H.,
2020. Association of blood glucose control and outcomes in patients with COVID-19 and pre-existing type 2
diabetes. Cell metabolism.
PowerPoint Presentation Date 23
OUTLINE
PERKENI RECOMMENDATION
https://pbperkeni.or.id/pernyataan-resmi-dan-rekomendasi-penanganan-diabetes-mellitus-di-era-pandemi-covid-19/
PowerPoint Presentation Date 26
PERKENI RECOMMENDATION
https://pbperkeni.or.id/pernyataan-resmi-dan-rekomendasi-penanganan-diabetes-mellitus-di-era-pandemi-covid-19/
MANAGEMENT OF PEOPLE WITH DIABETES INFECTED WITH COVID-19
RECOMMENDATIONS
Anti-diabetic Maintain
Monitoring
medication glycaemic control
• Patients should follow the • Blood glucose levels should be frequently • Management of COVID-
advice of the physician checked (generally, every 2-3 hours) 19 infection by patient
(diabetes care team) on and HCPs should follow
adjustments to their anti- sick day rules appropriate
diabetic medication(s) to any other infection
• Patients should be aware
of signs and symptoms of
hyperglycaemia
General:
1) Patients are advised to drink lots of fluids to stay hydrated. To avoid dehydration, patients should have small sips every 15 minutes or so
throughout the day if they are having trouble keeping water down.
2) Hands should be washed, and injection/infusion and finger-stick sites should be cleaned with soap and water or rubbing alcohol.
3) Recommendations of local authority should be followed if suspected of COVID-19 symptoms.
Blood glucose should For critical cases, early • During the 4-week follow-up
period after discharge, blood
be controlled for all identification and timely glucose homeostasis should be
patients during reduction adverse drug maintained continuously and
hospitalization to reaction (for instance, patients need to avoid infectious
glucocorticoid-induced diseases due to a lower immune
monitor the progress response. Long-term follow-up is
hyperglycemia) could
of illness and avoid prevent worse still essential for diabetic patients
aggravation. to reduce diabetes-related
symptoms. complications and mortality
Critical After
Hospitalized
Case discharge
For the COVID-19 patients with diabetes, tailored therapeutic strategy and optimal goal of glucose control
should be formulated based on clinical classification, coexisting comorbidities, age and other risk factors.
https://www.diabetesresearchclinicalpractice.com/article/S0168-8227(20)30368-5/pdf
Target stratification of glucose management:
ü For mild and moderate non-elderly COVID-19 patients, stick to strict high control
target
ü For mild and moderate elderly patients, or patients who have been using
glucocorticoid, set up a low or medium control target
ü For severe and critical patients, elderly patients, hypoglycemia intolerable patients,
or patients who have organ dysfunction or serious cardiovascular and
cerebrovascular diseases, set up a low control target
Target stratification of glucose management in hospitalized patients
CORTICOSTEROID-INDUCED
HYPERGLYCEMIA
• Steroids are the main cause of drug-induced hyperglycemia.
• Patients with known diabetes à exacerbate hyperglycemia
• Patients without documented hyperglycemia before the initiation of
glucocorticoids (GC) therapy à cause DM , with an incidence that can reach up
to 46% of patients, and increases in glucose levels up to 68% compared to
baseline.
• Precipitate acute complications à nonketotic hyperosmolar state, and diabetic
ketoacidosis.
• Patophysiology: Increase in insulin resistance with increased glucose production
and inhibition of the production and secretion of insulin by pancreatic β-cells
Tamez-Pérez HE et al . Steroid hyperglycemia: A narrative review. World J Diabetes 2015 July 25; 6(8): 1073-1081
PowerPoint Presentation Date
Bornstein, S.R., Rubino, F., Khunti, K., Mingrone, G., Hopkins, D., Birkenfeld, A.L., Boehm, B., Amiel, S., Holt, R.I., Skyler, J.S. and DeVries, J.H., 2020.
Practical recommendations for the management of diabetes in patients with COVID-19. The lancet Diabetes & endocrinology.
Use of antidiabetic medications in patients with T2DM and COVID-19
41
JBDS-IP, 2014
PowerPoint Presentation Date
42
TREATMENT OF HYPERGLYCEMIA IN CRITICALLY
ILL PATIENTS
• Continuous IV insulin infusion à the most effective method for achieving
specific glycemic targets. Because of the very short half-life of circulating insulin,
IV delivery allows rapid dosing adjustments to address alterations in the status of
patients.
• IV insulin therapy à the glucose level should be maintained between 140 and
180 mg/dl (7.8 and 10.0 mmol/l).
• Transition to subcutaneously administered insulin à begin eating regular meals
or are transferred to lower-intensity care.
• A percentage (usually 75– 80%) of the total daily IV infusion dose is proportionately
divided into basal and prandial components & must be given 1– 4 h before
discontinuation of IV insulin therapy in order to prevent hyperglycemia
AACE/ADA consensus on inpatient glycemic control. Diabetes Care 2009 Jun; 32(6): 1119-1131.
04/02/2021
MANAGEMENT OF CORTICOSTEROID-
INDUCED HYPERGLYCEMIA
• In hospitalized patients, monitoring should start with capillary glucose determination from the
start of steroid treatment.
• Since almost 94% of cases of hyperglycemia develop within 1-2 d of initiation of steroid
therapy in the hospital setting, in nondiabetic patients who maintain glucose levels < 140
mg/dL without insulin requirements for 24-48 h, glycemic monitoring can be discontinued.
• in patients with glucose levels > 140 mg/dL with persistent insulin requirements, a basal/ bolus
subcutaneous insulin scheme must be established.
• in patients with severe and/or persistent hyperglycemia despite the subcutaneous scheme,
insulin by infusion pump should be started.
Tamez-Pérez HE et al . Steroid hyperglycemia: A narrative review. World J Diabetes 2015 July 25; 6(8): 1073-1081
CLINICAL SITUATIONS THAT INCREASE THE RISK FOR
HYPOGLYCEMIA AND HYPERGLYCEMIA IN THE HOSPITAL INCLUDE
THE FOLLOWING:
1. Changes in caloric or carbohydrate intake (“nothing by mouth” status, enteral nutrition, or
parenteral nutrition)
3. Failure of the clinician to make adjustments to glycemic therapy based on daily BG patterns
7. Use of long-acting sulfonylureas in elderly patients and those with kidney or liver insufficiency
AACE/ADA consensus on inpatient glycemic control. Diabetes Care 2009 Jun; 32(6): 1119-1131.
BG MONITORING
• Bedside BG monitoring with use of pointof-care (POC) glucose meters is performed before
meals and at bedtime in most inpatients who are eating usual meals.
• In patients who are receiving continuous enteral or parenteral nutrition, glucose monitoring is
optimally performed every 4 – 6 h.
• In patients who are receiving cycled enteral nutrition or parenteral nutrition, the schedule for
glucose monitoring can be individualized but should be frequent enough to detect
hyperglycemia during feedings and the risk of hypoglycemia when feedings are interrupted
• More frequent BG testing, ranging from every 30 min to every 2 h, is required for patients
receiving IV insulin infusions.
AACE/ADA consensus on inpatient glycemic control. Diabetes Care 2009 Jun; 32(6): 1119-1131.
PowerPoint Presentation Date 47
OUTLINE
üUnderlying diabetes mellitus risk factors for increased coronavirus disease 2019
(COVID-19) disease severity and worse outcomes, including higher mortality.
üPotential pathogenetic links between COVID-19 and diabetes mellitus include
effects on glucose homeostasis, inflammation, altered immune status and
activation of the renin–angiotensin–aldosterone system (RAAS).
üDuring the COVID-19 pandemic, tight control of glucose levels and prevention of
diabetes complications might be crucial in patients with diabetes mellitus to keep
susceptibility low and to prevent severe courses of COVID-19.
üTarget stratification of glucose management depends the disease severity
& improvement
04/02/2021
49 LESSON LEARNED
50
THANK YOU