At a local hospital, a person in their mid-40s, with type 2 diabetes was admitted for treatment of COVID-19 and Diabetes Ketoacidosis (DKA). An insulin drip was started and their SGLT-2 Inhibitor was stopped.

How do we help prepare people with diabetes for the possibility of hospitalization and what are best practices to care for people with diabetes and COVID-19 in the hospital setting?

The American Diabetes Association (ADA) is providing a flurry of webinars and Town Hall Meetings to help diabetes care professionals keep pace with the latest developments on the impact of COVID and people living with diabetes.

COVID-19 & Inpatient Care for People with Diabetes

On April 9, a panel of experts (see below) shared their clinical opinions on the best inpatient practices for treating people with diabetes and COVID-19. I have highlighted some key questions and summarized responses from the broadcast of this expert panel.

Question: If a person with diabetes gets COVID-19 and is admitted to the hospital, what should they bring with them?

Answer: People with diabetes need to bring extra supplies so they can monitor glucose levels in between nursing check-ins and alert the staff of any urgent issues. The more people with diabetes can participate in their care, the better.

Supplies people with diabetes need to bring to the hospital include:

• Glucose meter with extra strips and lancets
• Continuous glucose monitor (CGM) and supplies
• Insulin Pump and supplies

Question: What are recommendations for people with type 1 who are using SGLT-2 Inhibitors or other medications (off-label) as an adjunct to insulin therapy?

Answer: Since SGLT-2 Inhibitors are associated with increased risk of Diabetes Ketoacidosis (DKA) and people with type 1 diabetes and COVID are at a higher risk of DKA, the panel recommended that during this epidemic, people with type 1 do not use SGLT-2 Inhibitors.

Basal bolus insulin therapy is the best and safest strategy to manage diabetes.

Question: What is the link between type 2 diabetes, body weight and outcomes with COVID infection?

Answer: Most hospital admissions with COVID are for people with type 2 diabetes. Although more research is needed, there seems to be an inter-relationship between excess weight, dyslipidemia, coronary disease proinflammatory state, plus the cytokine storm from the COVID-19 infection, that is contributing to worse outcomes for people with type 2 diabetes.

In addition, those with diabetes and excess weight are at risk of decreased lung function due to restrictive lung disease. And people with hyperglycemia are at higher risk of infection due to diminished white blood cell activity and depressed immunity. All of these combined factors are impacting recovery from COVID infection.

Have your hospitals experienced more DKA in people with type 2 diabetes and COVID?

Answer: There has been an alarming number of people with type 2 diabetes and COVID-19 presenting with DKA. This is possibly due in part to a combination of the overwhelming infection and the cytokine storm.

It is important that DKA in type 2’s is quickly recognized and aggressively treated to get blood glucose target as soon as possible.

Question: How do the nursing staff safely monitor blood glucose levels and deliver insulin therapy to people with diabetes and COVID-19?

Nursing staff is combining multiple activities along with blood glucose checks (vitals, med administration, and check-ins) to limit unnecessary exposure.

In addition, in the non-critical care units, nursing is partnering with individuals and having them check their blood sugars using their own meters or CGMs, in between nursing checks, to determine if action is needed. Of course, treatment is based on the hospital point of care device results, but people can self-monitor and alert the nursing staff of blood sugars that need attention.

As a matter of fact, the FDA is supportive of the inpatient’s use of CGMs in the non-ICU setting during the COVID, especially considering the benefits of alarms that alert staff and individuals of highs or lows.

One creative idea for inpatients using CGM, who may be too ill to keep track of glucose levels, is to place someone near the nursing station and put the CGM receiver outside the door, so the nursing staff can visualize blood sugars levels and monitor trends. This strategy was well received by the nursing staff and was a win-win for safety while limiting exposure.

I personally want to thank the American Diabetes Association for their expansive and timely COVID resources that are available during this crisis. More free ADA Webinars on Diabetes and COVID are available here.

Here is an article published in Endocrine Today that explores outcomes for people with diabetes and COVID-19.

The Panel of Experts Town Hall Experts Include:

Shivani Agarwal, MD, MPH
Albert Einstein College of Medicine

Jennifer Clements, PharmD, FCCP, BCPS, CDE, BCACP
American Pharmacists Association

Robert Eckel, MD
ADA President, Medicine & Science

Irl Hirsch, MD
University of Washington

Melanie Mabrey, DNP
Co-Chair – American Association of Nurse Practitioners – Endocrine Specialty Practice Group

Jane Jeffrie-Seley, DNP, BC-ADM, CDCES
Association of Diabetes Care and Education Specialists

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