Covid-19 and diabetes patients, recommendations and study results at a glance
The statements of the DDG show how strongly the new coronavirus disease (Covid-19) affects the situation of patients with diabetes. Due to the pandemic, there are currently far fewer urgent preventive and treatment appointments, which can lead to severe hypoglycemia. Guideline-based therapy with good blood sugar control is important in the pandemic situation
Risk assessments based on previous pandemics
According to Research, the current data situation does not justify excluding patients with diabetes from public life only because of their illness. The World Health Organization (WHO) warns of possible increased complication rates in diabetes patients with a Covid 19 infection.
The Robert Koch Institute (RKI) also sees particular risks for older diabetes patients and those with secondary diseases. However, these risk warnings are based on previous pandemic experiences. With regard to Covid-19, the first data available so far, mainly from China, only allow limited clinical conclusions
Difference between risk of infection and risk of complications
The results so far indicate that there is no generally increased risk of SARS-CoV-2 infection for diabetes patients with good blood sugar control. On the other hand, they may experience a less favorable course of the infection
Data from China
Most of the publications available so far deal with data from China. These include some reviews that examined the connection between diabetes and Covid-19. However, it lacks detailed information, for example on the type of diabetes or the hyperglycemic
Meta-analyzes on the connection between Covid-19 and diabetes
Current hypotheses on Covid 19 diabetes Pathomechanism
There is currently a lack of clinical data on how Covid-19 and diabetes are related.3 the angiotensin-converting enzyme 2 (ACE2) on the cell surface, to which the surface proteins of SARS-CoV-2 bind, plays a central role in the scientific discussion on possible Pathomechanism to penetrate human cells. ACE2 has protective properties with regard to inflammatory reactions. Among other things, these two pathophysiological hypotheses are discussed
SARS-CoV-2 intervenes via ACE2 in endocrine metabolic pathways that regulate blood pressure and inflammation, among other things. The virus reduces ACE2 expression and thus induces cell damage, severe inflammatory reactions and lung failure. Acute hyperglycemia can increase ACE2 expression and thus promote the penetration of SARS-CoV-2. In contrast, chronic hyperglycemia reduces ACE2 expression, which among other things increases the susceptibility of cells to inflammation. It is conceivable that ACE2 associated metabolic pathways are disrupted in patients with a severe Covid-19 course, which is particularly the case with diabetes and insulin resistance.
The related SARS pathogen is known to bind to ACE2 on the isle to cells of the pancreas, damage them and reduce the secretion of insulin by the beta cells. The affected patients developed temporary type 2 diabetes. Some Covid-19 treatment centers informally report severe diabetic ketoacidosis in newly admitted patients and a high need for insulin in the case of severe disease courses
The Pathophysiological role of the enzyme Dipeptidyl peptidase-4 (DPP4) and the use of DPP4 inhibitors in Covid-19.5,6 are also still unclear Hyperglycemia: This is how it generally affects the immune system
A lack of glycemic control generally disrupts the functionality of the immune system, which can negatively affect the course of an infectious disease. Hyperglycemia can, among other things, reduce the Degranulation of Neutrophils, alter the gene expression of cytokines and chemokines, reduce the phagocytic function of monocytes and inhibit the effect of complements. 7 Hyperglycemia and type 2 diabetes lead to a metabolic inflammation that can increase the release of cytokines. A so-called cytokine storm is involved in multiple organ failure in seriously ill Covid-19 patients New laboratory data on the stability of SARS-CoV-2 For infection control measures, it is important to better understand the “survivability” of the coronavirus ‘. New stability data from laboratory tests show the course over time of the SARS-CoV-2 titer under 5 environmental conditions. The main results: Aerosol: Viable SARS-CoV-2 particles were still detectable after 3 hours (duration of the experiment), with a greatly reduced titer at the same time. Surfaces: Viable SARS-CoV-2 particles were still present on plastic and stainless steel after 72 hours – with a greatly reduced titer. In contrast, no reproductive coronaviruses were detectable on copper after 4 hours and on cardboard after 24 hours. Under laboratory conditions, the half-lives for SARS-CoV-2 were 8 Table 2 These results depend on the initial amount of virus particles. 8 7 recommendations: Covid-19 in patients with diabetes The recommended infection protection measures for patients with diabetes such as those of the DDG concentrate mainly on 2 aspects: 9 Stable blood sugar control and blood pressure values Careful compliance with hygiene and contact minimization rules However, what applies if patients with diabetes develop Covid-19 despite all prevention? In addition, 7 recommendations as a general orientation from Dr. Thorsten Siegmund, specialist in general internal medicine, endocrinology and diabetology at the Isarklinikum in Munich: 9.10 Increase the amount of water you drink: Because fever, diarrhea and vomiting increase the fluid requirement. Measure your fever regularly: if you have a fever, your need for insulin can increase within hours. As a rule of thumb, if you have a fever without diarrhea or vomiting, the insulin dose increases by 10% to 25% for every degree Celsius increase in body temperature above 37.5 ° C. This general guideline is to be seen as a guide only. In some cases, there can be considerable, individual differences. The insulin dose is therefore only adjusted based on the measured blood sugar level. If you have a fever, measure glucose ** more frequently: In the first days of the infection, it is important to check the glucose every 2 to 3 hours in order to quickly determine any fluctuations.
For children with diabetes, measurements every 2 hours are recommended, as their metabolism can derail even faster. Checking ketones: In patients who require insulin, regular ketone testing in the blood (if not possible, alternatively in the urine) is important. An increased detection can indicate a serious disturbance of the blood sugar balance. Beware of diarrhea and vomiting: both can make insulin dosing difficult. Hourly glucose checks are therefore recommended in the event of gastrointestinal symptoms. It can also be useful to inject insulin after meals, when it is clear what the patient is keeping. Inpatient treatment is often necessary for diabetes patients with diarrhea or vomiting and an excessively high glucose level or ketoacidosis. Adjust medication individually: The insulin requirement can increase during an infection associated with fever (see 2.), but sometimes also decrease with gastrointestinal infections (see 5.). In addition to an individual dose adjustment, it may be necessary in individual cases to change the form of insulin (slow or fast-acting insulin) for the duration of the infection. The dosage of some oral anti-diabetic drugs can also change due to the infection. The guideline of the German Society for General Medicine and Family Medicine (DEGAM) on Covid-19 also recommends monitoring the administration of drugs that can induce the ACE2 receptor. 11 Control high glucose levels with additional insulin doses: If the blood sugar level is> 270 mg / dl (15 mmol / l) without detection of ketones, an additional dose of 2 to 8 IU of fast-acting insulin is recommended (initially the usual correction dose). Further insulin injections take place every 3 hours until the blood sugar level drops to <270 mg / l (15 mmol the usual correction insulin dose should be doubled, the correction interval should be reduced to 2 hours, contact with a doctor or hospitalization required. After all, in the case of an acute infection, it is particularly important that patients with diabetes strictly adhere to the recommendations of doctors and nurses.