Guidance on the management of Diabetic Ketoacidosis in the exceptional circumstances of the COVID‐19 pandemic

Rayman, Gerry; Lumb, Alistair; Kennon, Brian; Cottrell, Christine; Nagi, Dinesh; Page, E.; Voigt, D.; Courtney, Hamish; Atkins, H.; Platts, Julia; Higgins, Kath; Dhatariya, Ketan; Patel, Mayank; Narendran, Parth; Kar, Partha; Newland‐Jones, Philip; Stewart, Rose; Burr, O.; Thomas, Stephen

doi:10.1111/dme.14328

Cited by 46 publications

(50 citation statements)

References 5 publications

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“…The association between Covid-19 and hyperglycemia in elderly patients with T2D ( 60 ) seems likely to reflect metabolic inflammation and exaggerated cytokine release. Strikingly, recent data suggest that SARS-CoV2 infection can lead to a deterioration in glycemic control, involving both profound insulin resistance (requiring as much as 50–100 U insulin/h) and impaired insulin secretion, together leading to diabetic ketoacidosis, DKA ( 61 , 62 ). Thus, frequent cases of severe DKA have been observed on admission to hospital of patients with Covid-19 ( 14 ) and contribute to mortality and morbidity ( 9 ).…”

Section: Covid-19 and Diabetes: A Vicious Circle?mentioning

confidence: 99%

Covid-19 and Diabetes: A Complex Bidirectional Relationship

et al. 2020

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Covid-19 is a recently-emerged infectious disease caused by the novel severe acute respiratory syndrome coronavirus SARS-CoV2. SARS-CoV2 differs from previous coronavirus infections (SARS and MERS) due to its high infectivity (reproduction value, R 0 , typically 2–4) and pre- or asymptomatic transmission, properties that have contributed to the current global Covid-19 pandemic. Identified risk factors for disease severity and death from SARS-Cov2 infection include older age, male sex, diabetes, obesity and hypertension. The reasons for these associations are still largely obscure. Evidence is also emerging that SARS-CoV2 infection exacerbates the underlying pathophysiology of hyperglycemia in people with diabetes. Here, we discuss potential mechanisms through which diabetes may affect the risk of more severe outcomes in Covid-19 and, additionally, how diabetic emergencies and longer term pathology may be aggravated by infection with the virus. We consider roles for the immune system, the observed phenomenon of microangiopathy in severe Covid-19 infection and the potential for direct viral toxicity on metabolically-relevant tissues including pancreatic beta cells and targets of insulin action.

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Section: Covid-19 and Diabetes: A Vicious Circle?mentioning

confidence: 99%

Covid-19 and Diabetes: A Complex Bidirectional Relationship

et al. 2020

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“…Type 1 Diabetes Mellitus and Diabetic ketoacidosis One study reported that a large number of patients with COVID-19 developed diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS) or a combination of both [29]. It has also been found that COVID-19 may mask the symptoms of DKA [30].…”

Section: Special Situationsmentioning

confidence: 99%

Basal-Bolus Insulin Regimen for Hospitalised Patients with COVID-19 and Diabetes Mellitus: A Practical Approach

et al. 2020

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Background and Aim: The coronavirus disease 2019 (COVID-19) outbreak has rapidly crossed international boundaries and placed increasing demands on healthcare facilities worldwide. Patients with diabetes and uncontrolled blood glucose levels are at increased risk for poor clinical outcomes and in-hospital mortality related to COVID-19. Therefore, achieving good glycaemic control is of paramount importance among hospitalised patients with COVID-19. Basal-bolus insulin therapy is a safe and effective intervention for the management of hyperglycaemia in hospitalised patients. The aim of this article is to provide a practical guidance for the use of the basal-bolus insulin regimen in hospitalised patients with COVID-19 and diabetes mellitus. Methods: This guidance document was formulated based on the review of available literature and the combined personal experiences of the authors. We provide a comprehensive review on the use of the basal-bolus insulin regimen, including its principles, rationale, indications, prerequisites, initiation, and dose titration, and also suggest targets for blood glucose control and different levels of capillary blood glucose monitoring. Various case scenarios are used to illustrate how optimal glucose control can be achieved, such as through adjustments in doses of prandial and basal insulin, the use of correctional insulin dosing and changes in the timing and content of major and minor meals. Conclusion: The practical guidance for the use of the basal-bolus insulin regimen in hospitalised patients with COVID-19 and diabetes mellitus presented here can be used for patients admitted to hospital for indications other than COVID-19 and for those in ambulatory care.

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“…In large case series, COPD was present in only 11% in China, 1 5% in the United States 2 and 18% in the UK 3 ; but, by contrast, diabetes was present in 8%, 1 33.8% 2 and 21% 3 of cases, respectively. In addition, marked insulin resistance with ketosis has been reported, 4,5 even in those individuals with no preceding history of diabetes 5,6 …”

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confidence: 99%

Diabetes, obesity and COVID‐19: A complex interplay

Vas

Hopkins

Feher

et al. 2020

Diabetes Obesity Metabolism

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With the accumulation of observational data showing an association of metabolic co‐morbidities with adverse outcomes from COVID‐19, there is a need to disentangle the contributions of pre‐existing macro‐ and microvascular disease, obesity and glycaemia. This article outlines the complex mechanistic and clinical interplay between diabetes and COVID‐19, the clinical and research questions which arise from this relationship, and the types of studies needed to answer those questions. The authors are clinicians and academics working in diabetes and obesity medicine, but the article is pitched to an audience of generalists with clinical experience of or interest in the management of COVID‐19.

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Guidance on the management of Diabetic Ketoacidosis in the exceptional circumstances of the COVID‐19 pandemic

Abstract: We hope that most teams will not find it necessary to use the subcutaneous insulin route to manage DKA, but we understand that this regimen has been welcomed by some working in less well-resourced countries.

Cited by 46 publications

References 5 publications

Covid-19 and Diabetes: A Complex Bidirectional Relationship

Covid-19 and Diabetes: A Complex Bidirectional Relationship

Basal-Bolus Insulin Regimen for Hospitalised Patients with COVID-19 and Diabetes Mellitus: A Practical Approach

Diabetes, obesity and COVID‐19: A complex interplay

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