Lifestyle Management During and After

COVID- 19 for Diabetic and Cardiac Patients

Speaker Name:Dr. Saghir Abdur Rahim

Designation: Deputy chief Medical officer
Institution:BIRDEM General Hospital

MAT-BD-2100207
 Background
• Coronavirus disease-2019 (COVID- 19) pandemic
declared by the World Health Organization (WHO) on
11th March 2020, caused by SARS-CoV-2 virus is at
exponentially rising state across the globe.

• Globally more than 213 countries are reported to have

the pandemic going on and the situation is evolving
rapidly with global case counts and deaths increasing
each day.

• Dated till April 18, 2021-

 Number of global cases: 182,261,595

 Number of global deaths: 3,947,464

 Number of cases in Bangladesh: 896,770 Coronavirus Daily New Cases in Bangladesh

 Number of deaths in Bangladesh: 14,276

Source: National Guidelines on Clinical Management of Coronavirus Disease 2019 (Covid-19); Version 7.0
https://www.worldometers.info/coronavirus/country/bangladesh/
 Virology

● There are two major types (or strains) of the SARS-

CoV-2 virus in China, designated L and S.

● The B.1.1.7, B.1.351, P.1, B.1.427, and B.1.429

variants circulating in the United States are
classified as variants of concern

● Variants are changing with time

Source: National Guidelines on Clinical Management of Coronavirus Disease 2019 (Covid-19); Version 5.0;
About Variants of the Virus that Causes COVID-19​​| CDC
Vulnerable Populations

https://preventepidemics.org/covid19/science/
insights/returning-to-work/
Cardiovascular involvements by SRAS-CoV2 infection

https://doi.org/10.1016/j.amjms.2020.10.002
HOW COULD THE DISEASE
BE AVOIDED?

Source: INFORMATION ON CORONA-VIRUS DISEASE 2019

(COVID-19) OUTBREAK AND GUIDANCE FOR PEOPLE WITH
DIABETES
 Challenges in Diabetes management

 Difficulties in effective implementation of lifestyle measures particularly with respect to physical

activity and exercise.
 Stress and the higher levels of anxiety and depression during periods of lockdown not only affect the
mental health and sleep of the diabetic patient but also adversely affect glycemic control.
 Adherence to healthy diet and access to healthcare is limited by infection control measures in the
community
 Appropriate use of various antidiabetic agents is another area of concern as well as an area of intense
speculation and debate as advisories not always supported by well-designed studies, are often confusing
the treating physician.

Research Society for Study of Diabetes in India 2020, https://doi.org/10.1007/s13410-020-00831-6

 What We Learn !!!
 Insulin appears to be a good option for glycemic
control and is safe.
 Anti-hyperglycemic drugs that cause volume
depletion or hypoglycemia are best avoided or used
in small dosages.
 The relationship of ACE and COVID-19 infections
particularly pneumonias and ARDS is complex.
While reduced ACE2 expression in DM is believed
to predispose COVID patients to severe pneumonias
and ARDS, it has also been postulated that ACE2
expression promotes entry of SARS CoV-2 virus into
host pneumocytes. There is no clear evidence that
would suggest withdrawing ACE inhibitors or ARBs
in these patients, and hence, most international
societies do not recommend stopping them.

Research Society for Study of Diabetes in India

2020, https://doi.org/10.1007/s13410-020-00831-6
Considerations for Management of Diabetes During
National Emergencies

Diabetes and COVID-19: Risks, Management, and Learnings From Other National Disasters; https://doi.org/10.2337/dc20-1192
Are people with DIABETES more likely to get COVID-19?

There is not enough data to show whether people with

diabetes are more likely to get COVID-19 than the general
population.
The problem people with diabetes face is they’re more
likely to have Worse Complications if they get it, not
greater chance of getting the virus.
Also, the more health conditions someone has for
example, Diabetes Plus Heart Disease , adds to their
risk of getting those serious complications from COVID-19.
Older people are also at higher risk of complications if
they get the virus.
 How Does COVID-19 Affect Those With DIABETES?

● Diabetes in 42.3% of 26 fatalities due to COVID-19 in Wuhan,

China1

3 fold higher mortality

● A report of 72,314 cases of COVID-19: increased mortality in rate in diabetes2
people with diabetes (2.3%, overall vs 7.3%,patients with
diabetes)2

● Coexisting disease of heart, kidney, advanced age and frailty are

likely to have further increase in severity
People with diabetes do face a higher
chance of experiencing serious
complications from COVID-191

COVID-19 – Coronavirus disease-2019

SARS-CoV-2 - severe acute respiratory syndrome coronavirus-2
1. Gupta R et.al. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 211e212
11
2. Wu Z et.al. J Am Med Assoc (2020 Feb 24), 10.1001/jama.2020.2648
 Reasons of glucose fluctuation in people with
DM and COVID-19
People with DM may develop hypoglycemic or acute hyperglycemic complications due to following
reasons:

1. Irregular diet, reduced exercise, gastrointestinal (GIT) symptoms, etc., affect diet resulting in
glucose fluctuation.
2. Stress conditions like infection increase glucocorticoids secretion.
3. The use of glucocorticoids in treatment can lead to a sharp rise in glucose.
4. There may be interruption or non-standard treatment with oral agents in isolation wards, resulting in
glucose fluctuation.
5. Fear, anxiety, and tension may increase glucose level and induce glucose fluctuation.
6. COVID-19 can cause human body to produce a large number of inflammatory cytokines and lead to
extreme stress in some severe and critical patients.

If these develop, should be treated urgently as per standard protocols.

BADAS Guide on COVID- 19 and Diabetes for Healthcare Professionals

 What Are The Specific Precautions For People
With DIABETES?

Good glycemic control Frequent monitoring Stabilize cardiac/renal status

(Reduces risk & severity of infection) (Use of SMBG should be encouraged) (Reduce chances of serious complications)

Proper nutrition Regular exercise Self-quarantine

(Correct deficiency of vitamins & minerals) (Improves immunity, Avoid crowded places) (Especially in high risk patients like elderly)

Influenza & pneumonia vaccinations may lessen chances of secondary bacterial pneumonia

SMBG – Self monitored blood glucose

Gupta R et.al. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 211e212
13
 Categorized Guidance to Manage Diabetes
in Critical Infections
General guidelines to manage diabetes during COVID-19 1
• Take diabetes medication as usual. Insulin treatment should never be
stopped
• Test blood glucose every four hours, and keep track of the results
• Drink extra (calorie-free) fluid*, and try to eat as normal
• Weigh yourself every day. Losing weight while eating normally is a sign of
high blood glucose
• Check temperature every morning and evening. A fever may be a sign of
infection
Individualized target based treatment strategies 2
Patient BG Targets Management
Category FPG 2h PG

1. International Diabetes Federation, sick day rules Accessed 8 Mildly ill Patients 4.4-6.1mmol/L 6.1-7.8mmol/L Maintain Strict Glycemic
March 2020.
2. Sichuan Da Xue Xue Bao Yi Xue Ban. 2020 Mar;51(2):146-
Control
150.
© 2020 Eli Lilly and Company. Moderately ill 6.1-7.8mmol/L 7.8-10.0mmol/L Subcutaneous Insulin
Delivery system
Critically Ill 7.8-10.0mmol/L 7.8-13.9mmol/L IV Insulin Infusion
How can we prepare ourselves?
Consensus recommendations for COVID-19 and
Therapeutic Aims of Diabetes Management

Plasma Glucose CGM/FGM

Concentration HbA1c
Targets
• TIR (3·9–10 mmol/L):
more than 70%
4–8 mmol/L (>50% in frail and older people)
<53 mmol/mol (<7%)
(72–144 mg/dL)
• Hypoglycaemia (<3·9
mmol/L):
less than 4%
(<1% in frail and older people)

Practical recommendations for the management of diabetes in patients with COVID-19,https://doi.org/10.1016/

 Should anti-diabetic medications be
reconsidered amid COVID-19 pandemic

https://doi.org/10.1016/j.diabres.2020.108146
 SMBG Frequency

Bangladesh Endocrine Society (BES)-Practical Recommendations for Management of

Diabetes and Other Endocrine Diseases in Patients with COVID-19
 Treatment of DM in COVID-19:
Anti-diabetic Agents – Oral and Parenteral

Recommendations for management of diabetes according to severity

Bangladesh Endocrine Society (BES)-Practical Recommendations for Management of

Diabetes and Other Endocrine Diseases in Patients with COVID-19
 Treatment of DM in COVID-19:
Anti-diabetic Agents – Oral and Parenteral

Insulin initiation according to different insulin regimens

Bangladesh Endocrine Society (BES)-Practical Recommendations for Management of

Diabetes and Other Endocrine Diseases in Patients with COVID-19
Issues with anti-diabetic Medications in
COVID-19 Pandemic
SGLT2 Inhibitors
Metformin

• Dehydration and lactic acidosis will probably

occur if patients are dehydrated, so patients should
stop taking the drug and follow sick day rules.
• During illness, renal function should be carefully
monitored because of the high risk of chronic
kidney disease or acute kidney injury.
• Risk of dehydration and diabetic ketoacidosis
during illness, so patients should stop taking the
drugs and follow sick day rules
• Patients should avoid initiating therapy during
respiratory illness
• Renal function should be carefully monitored for
acute kidney injury

GLP-1 Receptor Agonists

Dipeptidyl Peptidase-4 Inhibitors
• Dehydration is likely to lead to a serious illness
so patients should be closely monitored
These drugs are generally well tolerated and can
be continued
• Adequate fluid intake and regular meals should
be encouraged

Practical recommendations for the management of diabetes in patients with COVID-19,https://doi.org/10.1016/

Potential benefits or risks of antidiabetic agents in the
context of coronavirus infections

Front. Pharmacol., 29 January 2021 | https://doi.org/10.3389/fphar.2020.592439

Potential benefits or risks of antidiabetic agents in the
context of coronavirus infections

Front. Pharmacol., 29 January 2021 | https://doi.org/10.3389/fphar.2020.592439

Management of Co-morbidities of Diabetes
in COVID-19

Recommendations for drugs used for co-morbid diseases of diabetes

Bangladesh Endocrine Society (BES)-Practical Recommendations for Management of

Diabetes and Other Endocrine Diseases in Patients with COVID-19
WHAT TO DO IF INSTRUCTED TO STAY AT HOME?

 Monitoring for clinical deterioration of patient,

which may need prompt hospitalization.

 Affected persons should be placed in a well-

ventilated single room, household members should
stay in a different room or, if that is not possible,
maintain a distance of at least 1 m from the ill person
(e.g., sleep in a separate bed).

 Perform hand hygiene (washing of hands with soap

and water, preferable to use disposable paper towels
to dry them) after any type of contact with patients
or their immediate environment.

 When coughing or sneezing, a medical mask or

disposable paper tissue should be used the patient to
contain respiratory secretions.

Source: INFORMATION ON CORONA-VIRUS DISEASE 2019 (COVID-19) OUTBREAK AND GUIDANCE FOR PEOPLE WITH DIABETES
 Home-based Exercise for People with Diabetes
Below are a series of daily exercises that can be performed at home.
The exercise intensity of each activity is comparable to one hour of brisk walking, resulting in an energy
expenditure of 150-200 Kcal.

• Treadmill: one-hour brisk walking (no need to run), which can also be split into three 20-minute sessions. If
possible, the slope should be adapted to individual fitness levels, to simulate an uphill walk.
• Stationary bicycle (either reclined or classic): two 15-minute sessions at variable intensity (if the equipment
allows it). The sessions can be longer on a reclined bicycle since the effort is reduced by the backrest.
• Bodyweight exercises such as push-ups, squats, deep stationary lunges, sit-ups or crunches (to strengthen the
abdomen) and forward flexes (to strengthen the lower-back muscles). These help maintain muscle tone and,
when performed correctly, can have excellent results.
• Joint mobility and stretching exercises that can be sourced from common workout, yoga and Pilates'
routines.

https://www.idf.org/aboutdiabetes/what-is-diabetes/covid-19-and-diabetes/home-based-exercise.html
 Should I wear a face mask?

https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-
use-masks
https://www.news18.com/news/india/coronavirus-pandemic-after-who-us-india-urges-use-of-masks-
outdoors-releases-diy-guide-for-face-covers-2564211.html
https://preventepidemics.org/covid19/science/insights/box-it-in/
https://preventepidemics.org/covid19/science/insights/box-it-in/
 Key Considerations

People with diabetes have greater chances of serious complications from COVID-19

People with diabetes are at increased risk of mortality from COVID-19

Risk & severity of COVID-19 in people with diabetes can be reduced with general
precautions, good glycemic control and proper monitoring
Antidiabetic agents combined with CGM might be a good treatment option for
COVID-19 patients, particularly for the critical patients

Insulin is the preferred agent for control of hyperglycemia in hospitalized patients

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