Post COVID 19 diabetes care lessons and challenges
The outbreak of COVID 19 all over the world this year has posed several new challenges to diabetes care and has also provided an opportunity for new lessons to be learnt in what seems to be transforming the way we treat diabetic patients. Some of the issues and challenges that have emerged include the reported high incidence [1, 2] of COVID 19 infections among patients with diabetes mellitus (DM) the greater severity, and higher rates of progression resulting in a higher number of ICU admissions [3] and higher mortality reported in them [1, 2] The increased predisposition of patients with diabetes to COVID 19 infections particularly severe infections with acute respiratory distress is believed to be related to a compromised innate immunity that accompanies uncontrolled DM and an exaggerated proinflammatory cytokine response involving IL 6 and TNF alpha [4] The situation would be worse if there are other comorbidities such as hypertension, chronic kidney disease, or coronary artery disease which often coexist with diabetes and are also associated with more aggressive COVID 19 infections. This calls for early and aggressive management of COVID 19 in diabetic patients to prevent adverse outcomes. It is equally important to detect fresh cases of diabetes early and pick up hyperglycemic spikes in those known to be diabetic without delay something which is very difficult at a time when the medical fraternity is struggling to manage the COVID 19 pandemic. A high degree of alertness with frequent self monitoring of blood glucose levels is certainly advisable in known diabetic patients particularly insulin users to reduce the risk of being affected with COVID 19 infection and avoid any undesirable consequence should they get infected. As physicians involved in diabetes care, we need to advise our patients accordingly besides telling them to follow with greater intensity all the general measures to prevent exposure to COVID 19 infection. Just as it is important that we target and make every effort to achieve good glycemic control during these COVID times, it is equally important that we identify diabetes comorbidities and complications early and effectively manage them. It is well known that several of these including hypertension, heart disease including heart failure, and chronic kidney disease are all associated with higher mortality in COVID 19 infections. Challenges in diabetes management begin with difficulties in effective implementation of lifestyle measures particularly with respect to physical activity and exercise. These are surmountable and can be largely met by advising indoor exercise routines, yoga, and other innovative ways of enhancing physical activity. Fortunately, limited access to fast foods and other unhealthy dietary choices in restaurants should help, but one should still be advised to judiciously choose from available homemade and packaged dietary choices. Poor access to alcohol and limited opportunities for smoking during lockdown can also become a unique opportunity to seriously consider giving up these habits which can help prevent long term complications of diabetes. Stress and the higher levels of anxiety and depression that can occur during periods of lockdown not only affect the mental health and sleep of the diabetic patient but also adversely affect glycemic control. Appropriate measures to relieve stress are also important to maintain glucose control. Another important challenge in the management of diabetes mellitus has been regarding the appropriate use of various antidiabetic agents. This has been an area of concern as well as an area of intense speculation and debate. Advisories, not always supported by well designed studies, are often confusing the treating physician. Overall, insulin appears to be a good option for glycemic control and is safe. It is advised that anti hyperglycemic drugs that cause volume depletion or hypoglycemia are best avoided or used in small dosages. Metformin may show a higher propensity to lactic acidosis especially in those with volume depletion. SGLT2 inhibitors are contraindicated not only because they are associated with fluid loss but these groups of agents have also been found to be associated with a higher incidence of diabetic ketoacidosis S. V. Madhu drsvmadhu@gmail.com
International Journal of Diabetes in Developing Countries