1) Diabetes is a major risk factor for severe illness from COVID-19, with studies showing people with diabetes are at higher risk of mortality. 2) Guidelines recommend people with diabetes who get COVID-19 closely monitor their blood glucose and follow sick day rules for diabetes. They may need adjusted diabetes medication dosages. 3) Some evidence suggests chloroquine or hydroxychloroquine may help treat COVID-19, but more research is still needed. Ibuprofen use is not recommended due to theoretical risks, and acetaminophen is preferred instead.

1. Management of COVID 19 &
Diabetes
Made By – Mr Amogh Lotankar

2. COVID-19
Coronavirus disease 2019, or "COVID-19"is the
infectious disease caused by the most recently
discovered coronavirus called SARS-CoV-2 (Severe
Acute Respiratory Syndrome-Coronavirus-2)
This new virus and disease were unknown before
the outbreak began in Wuhan, China, in
December 2019.

3. COVID-19 : Facts & Figures - INDIA
"Home | Ministry of Health and Family Welfare | GOI". www.mohfw.gov.in. as on : 14 April 2020,
08:00 GMT+5:30.

4. COVID-19 : Facts & Figures - INDIA
Updated: Apr 8, 2020, 11:17 IST
86 people who died. This showed that more than half of them (56%) were DIABETIC &
almost half (47%) had HYPERTENSION.
Read more at:
http://timesofindia.indiatimes.com/articleshow/75037820.cms?utm_source=contentofinterest&utm_medium=te
xt&utm_campaign=cppst
Over a third of the 86 had both DIABETES AND HYPERTENSION
Diabetes emerged as the leading co-morbidity among those
felled by the disease in INDIA is significant.
The fact that an estimated 9.4% of the country is diabetic — 12% of the urban
population and nearly 8% of rural

5. On March 11, 2020, the World Health Organization declared Coronavirus Disease 2019 (COVID-19) a pandemic
As of March 28, 2020, a total of 571,678 confirmed COVID-19 cases and 26,494 deaths have been reported
worldwide
Approximately one third of these patients (2,692, 37.6%), had at least one underlying condition or risk factor.
Out of which Diabetes mellitus (784, 10.9%) is the most common
COVID-19 : Facts & Figures - Worldwide
MMWRMorbMortalWklyRep.2020Apr3;69(13)382-386

6. Individuals with diabetes are at risk of infections, especially influenza and pneumonia.
patients with diabetes have a severe disease when infected with respiratory viruses.
diabetes was seen as an important risk factor for mortality in patients infected with
H1N1, SARS coronavirus & MERSCoV
Diabetes & COVID19 - Worldwide
Diabetes was present in 42.3% of 26 fatalities due to COVID-19 in
Wuhan, China
Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 211e212

7. People with diabetes have a higher overall risk of infection that results from multiple
perturbations of innate immunity.
the first three deaths related to COVID-19 in Hong Kong all occurred in people with
diabetes.
Likewise, 24% of those with severe disease had hypertension, compared to 13% among
those with mild disease.
highlighting the increased risk of adverse outcomes among those with chronic diseases
like diabetes.
Diabet.Med.00,1–3(2020)
Diabetes & COVID19 - Worldwide

8. The most distinctive comorbidities of 32 non-survivors of 52 intensive care unit patients
with novel coronavirus disease 2019 (COVID-19) were cerebrovascular diseases (22%) &
diabetes (22%). 1
1099 patients with confirmed COVID-19, of whom 173 had severe disease with
comorbidities of hypertension (23·7%), diabetes mellitus (16·2%), coronary heart
diseases (5·8%), and cerebrovascular disease (2·3%) 2
140 patients admitted to hospital with COVID-19, 30% had hypertension and 12% had
diabetes.3
1. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered,
retrospective, observational study. Lancet Respir Med 2020
2. Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020
3. Zhang JJ, Dong X, Cao YY, et al. Clinical characteristics of 140 patients infected by SARS-CoV-2 in Wuhan, China. Allergy 2020
Diabetes & COVID19 - Worldwide

9. Of the 25 deaths, All (25/25, 100%) of those who died had underlying diseases, the most
common of which was
Hypertension (16/25, 64%)
Diabetes (10/25, 40%)
the most important risk factors for death was hypertension, followed by diabetes 1
Diabetes : The risk factor for COVID 19
1. Int J Infect Dis. 2020 Apr 3. pii S1201-9712(20)30186-7
2. Diabetes Metab Res Rev. 2020 Mar 31e3319
DIABETES should be considered as a risk factor for a rapid progression and bad
prognosis of COVID-19.2

10. The overall case-fatality rate (CFR) at that stage was 2.3% (1,023 deaths of the 44,672 confirmed cases).
The data indicated that the CFR was elevated among COVID-19 patients with preexisting comorbid conditions,
specifically,
cardiovascular disease (CFR, 10.5%)
diabetes (7.3%)
chronic respiratory disease (6.3%)
hypertension (6%)
cancer (5.6%).
JAMA.2020;323(13):1239-1242
Diabetes & COVID19 – Mortality Rate
Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention
Patients with diabetes had a threefold higher mortality rate than did
those without diabetes (7.3% vs. 2.3%, respectively).

11. Measures to prevent COVID-19
A. General Preventive Measures:
Thorough handwashing with soap and water should be encouraged since it kills the virus.
Use of alcohol-based hand rubs is also useful.
There is a need to practise proper respiratory hygiene with covering of mouth and nose with bent
elbow or tissue when coughing or sneezing.
Touching of mouth, nose and eyes should be avoided.
Contact with an affected person needs to be minimised.
Use of recommended face masks is advised if there is a contact with someone with respiratory
symptoms.
Non-essential travel to major affected areas should be avoided in order to restrict the spread of
infection.
Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 211e212

12. Measures to prevent COVID-19
B. Specific Measures in Patients with Diabetes:
Maintain a good glycaemic control, as it might help in reducing the risk of infection and also the severity.
More frequent monitoring of blood glucose levels (with use of self-monitoring blood glucose) is required.
Good glycemic control may lessen chances of superadded bacterial pneumonia as well.
Patients with diabetes and co-existing heart disease or kidney disease need special care and attempts should
be made to stabilise their cardiac/renal status.
Attention to nutrition and adequate protein intake is important.
Any deficiencies of minerals and vitamins need to be taken care of.
Exercise has been shown to improve immunity, though it might be prudent to be careful and avoid crowded
places like gymnasia or swimming pools.
It is important to take influenza and pneumonia vaccinations. The latter may decrease chances of secondary
bacterial pneumonia after respiratory viral infection, however, data in present viral epidemic is not available
Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 211e212

13. Measures to prevent COVID-19
C. Measures in Patients of diabetes with COVID 19 infection:
In case a person with diabetes develops fever, cough, running nose or dyspnoea, the appropriate health
authority needs to be notified as testing for this disease is available at selected places only.
The affected person needs to be isolated for 14 days or till the symptoms resolve (whichever is
longer).Country-specific guidelines need to be followed.
Majority of patients have a mild disease and can be managed at home.
Hydration should be maintained and symptomatic treatment with acetaminophen, steam inhalation etc. can
be given.
Patients with type 1 diabetes should measure blood glucose and urinary ketones frequently if fever with
hyperglycemia occurs.
Frequent changes in dosage and correctional bolus may be required to maintain normoglycemia
Anti-hyperglycemic agents that can cause volume depletion or hypoglycemia should be avoided.
Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 211e212

14. Measures to prevent COVID-19
C. Measures in Patients of diabetes with COVID 19 infection:
Dosage of oral anti-diabetic drugs may need to be reduced.
Patients should follow sick day guidelines and may need more frequent monitoring of blood
glucose and drug adjustment.
Hospitalised patients with severe disease need frequent blood glucose monitoring.
Oral agents especially metformin and sodium glucose cotransporter-2 inhibitors need to be
stopped.
Insulin is the preferred agent for control of hyperglycemia in hospitalised sick patients.
Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 211e212

15. What should people with diabetes do
if they have the virus?
• People with diabetes who are infected with the virus may see their glycaemic control deteriorate during
the illness.
• They should practice the “Sick day rules” recommended for any stressful situation to improve their
diabetes decompensation.
Sick day rules for people with diabetes
• Keep hydrated
• Monitor your blood glucose
• Monitor your temperature
• If you are on insulin, also monitor your ketone bodies
• Follow your healthcare team recommendations

16. Management of COVID-19
Specific COVID - 19 treatments
As per the guidelines from Government of India Ministry of Health & Family Welfare –
Lopinavir/ Ritonavir should ONLY be used with proper informed expressed consent on a case to case basis for
severe cases, within the under-mentioned framework along with supportive treatment as per need.
Administration of Lopinavir/ Ritonavir to be considered in Laboratory confirmed cases of COVID – 19 when the following criteria are
met:
• Symptomatic patients with any of the following:
i. hypoxia
ii. Hypotension
iii. new onset organ dysfunction (one or more)
• Increase in creatinine by 50% from baseline, GFR reduction by >25% from baseline or urine output of <0.5 ml/kg for 6 hours.
• Reduction of GCS by 2 or more
• Any other organ dysfunction
iv. High Risk Groups: Age> 60 yrs Diabetes Mellitus, Renal Failure, Chronic Lung disease Immuno – compromised persons
• Dosage:
i. Lopinavir/ Ritonavir (200 mg/ 50 mg) – 2 tablets twice daily
ii. ii. For patients unable to take medications by mouth: Lopinavir 400mg/ Ritonavir 100 mg – 5ml suspension twice daily
• Duration: 14 days or for 7 days after becoming asymptomatic.

17. Practical recommendations based on current evidence
Indian Council of Medical Research (ICMR) has recommended prophylaxis with CQ or HCQ in asymptomatic
healthcare workers involved in the care of suspected or confirmed cases of COVID-19 & asymptomatic
household contacts of laboratory confirmed cases.
Management of COVID-19
Use of chloroquine(CQ) or hydroxychloroquine (HCQ)
Use of ibuprofen and other NSAIDs
World Health Organisation (WHO) first recommended against using ibuprofen in COVID-19,
however went back against its own advice and updated its advice soon to say that
“based on currently available information, WHO does not recommend against the use of
ibuprofen”.
Diabetes&MetabolicSyndrome:ClinicalResearch&Reviews14(2020)251e254

18. Management of COVID-19
Practical recommendations based on current evidence
Overall, it seems reasonable, but not mandatory, to avoid ibuprofen and other NSAIDs in COVID-19 infection
and use acetaminophen instead for control of fever and pain
Use of ibuprofen and other NSAIDs
Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 251e254
Use of drugs acting on renin angiotensin system
Practical recommendations based on current evidence
In view of lack of robust evidence for either benefit or harm, it is reasonable for patients to continue using
ACE inhibitors and ARB, as recommended by European Society of Cardiology Council on Hypertension,
European Society of Hypertension and American Heart Association

19. Drugs in pipeline for COVID-19
Diabetes&MetabolicSyndrome:ClinicalResearch&Reviews14(2020)241e246