Scientific Research Linking Diabetes and COVID-19 Complications

A small preliminary study published in the March 2020 issue of Diabetes Metabolism Research and Reviews looked at 174 people in Wuhan, China, and concluded that people with COVID-19 and diabetes but without other comorbidities were at a higher risk for severe pneumonia and the inflammation that contributes to an accelerated progression of COVID-19 and a worse prognosis.

Another study, which was published in April 2020 the Journal of Diabetes Science and Technology, analyzed 1,122 people at 88 hospitals in 11 U.S. states, and drew a link between diabetes and a fourfold increased risk of dying from COVID-19. Glytec, a provider of insulin software management, funded the research.

Other, more recent research, published online in May 2020 in Cell Metabolism, supports these findings. For this cohort study, researchers analyzed the health data of 7,337 people in Wuhan with and without type 2 diabetes. They observed an association between having diabetes and an increased risk of dying from COVID-19. Those with stable blood sugar levels had a better prognosis than those with diabetes whose blood sugar control was poor. In fact, the survival rate for those with good blood sugar control was nearly 99 percent, compared with an 11 percent death rate among those whose control was considered poor. Participants’ blood sugar levels were measured using postprandial and fasting blood glucose tests. The authors defined poor blood sugar control as tending to exceed 180 milligrams per deciliter (mg/dL), and well-controlled blood sugar as ranging from 70 to 180 mg/dL.

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Diabetes Complications Can Increase Risk of Severe Illness From COVID-19

Still, having complications related to diabetes, along with increasing age, may matter more than blood sugar control, suggested a study published in April 2020 in Diabetologia, which analyzed 1,317 people admitted to 53 French hospitals during a three-week period in March 2020. Study authors concluded that 10 percent of people with diabetes admitted to a hospital died within 10 days, and that men were more likely to die than women. The main contributing factors to death were having complications including neuropathy and heart disease, having a high body mass index (BMI) —indicating obesity — and being older. Patients between ages 65 and 74 were three times more likely to die than individuals younger than 55.

People with type 2 diabetes are definitely at higher risk of COVID-19 complications and death, but those with type 1 or gestational diabetes may also be at higher risk, according to recent guidance by the CDC. In the French study, 3 percent of admitted patients had type 1 diabetes, while 89 percent had type 2 diabetes. The remainder of diabetes patients had other types of the disease.

RELATED: How Obesity May Increase the Risk of COVID-19 Complications

Understanding COVID-19 and Its Symptoms

According to the World Health Organization (WHO), coronaviruses are a large family of viruses that cause diseases including the common cold, but also more severe illnesses, such as Middle East respiratory syndrome (MERS); severe acute respiratory syndrome (SARS); and COVID-19, which first became known at the end of 2019 during an outbreak in the city of Wuhan in China’s Hubei province and has since developed into a global pandemic.

According to the WHO, common symptoms of COVID-19 include:

Fever

Tiredness

Dry cough

Aches and pains

Nasal congestion

Runny nose

Sore throat

Loss of taste or smell

Skin rashes

Discolored fingers or toes

Diarrhea

Some infected people have no symptoms at all, but they can still spread the virus.

The CDC describes the emergency warning signs for COVID-19 in adults as:

Difficulty breathing or shortness of breath

Persistent pain or pressure in the chest

New confusion or inability to wake up or stay awake

Bluish lips or face

If you are experiencing these symptoms, call 911 or call ahead to the hospital and let them know you are seeking care for COVID-19 or may have it, the CDC advises.

If you are interested in getting a test and want to know how to proceed, contact your local or state health department. The CDC lists state and territorial departments, and the National Association of County and City Health Officials has a directory you can use to find your local department.

For most people, the disease is mild, and about 80 percent of those infected recover from COVID-19 without needing hospitalization or special treatment, according to a study published by the Chinese Center for Disease Control. Yet around 1 out of every 5 infected people do become seriously ill, develop difficulty breathing, and require hospital care. Mortality estimates vary, but the risk of death from COVID-19 is far greater than influenza (flu), a frequently made comparison. More than 187,000 people have died of COVID-19 in the United States during the first nine months of 2020, according to the tracker maintained by Johns Hopkins Medicine. In comparison, the nation loses between 12,000 and 61,000 people per year to influenza, reports the CDC.

RELATED: Answers to 7 Common Questions About the Coronavirus

Given all that, if you have diabetes and wish to stay in the best health possible during this pandemic, experts including Katherine Araque, MD, the director of endocrinology at the Pacific Neuroscience Institute at Providence Saint John’s Health Center in Santa Monica, California, have some advice.

1. Follow the CDC Guidelines —They're for Everyone

“We know that we should follow the CDC guidelines with regard to symptoms and when to test, regardless of the underlying diagnosis of diabetes,” says Dr. Araque.

Those guidelines include:

Clean your hands often with soap and hot water for at least 20 seconds, or use sanitizer that is at least 60 percent alcohol.

Avoid touching your eyes, nose, and mouth with unwashed hands.

Avoid close contact and practice social distancing (staying at least six feet apart).

Cover coughs and sneezes with a tissue. (Then clean your hands!)

Clean and disinfect frequently touched surfaces daily, and dirty ones immediately.

Stay home if you’re sick.

Separate yourself from others if you have been diagnosed with COVID-19 or think you have it.

Wear a face mask covering your mouth and nose outside of your home and when you're around people who don’t live in your household, particularly in settings where social distancing is hard to maintain.

Call ahead about medical attention unless you are having a medical emergency.

Of course, in this fast-moving pandemic, local, state, and federal regulations and guidelines are constantly shifting regarding meetings, gatherings, travel, working, and when you should stay at home. Follow the latest ones; they are meant to slow the spread of the virus.

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2. Keep Your Diabetes Treatment Supplies and Equipment Clean and Disinfected

“We advise our patients to please keep up hygiene at home, to keep washing their hands,” says Araque. “For patients with diabetes, it is important to wash their hands thoroughly before administering insulin or injectable medications.” They should also use soap and water to clean the areas on their body where they inject their medication. She further cautions patients not to share needles or pens, and to dispose of needles safely.

3. Keep Your Prescriptions Filled and Stock Up on Extra Supplies

“We want to ensure that those patients have all their medications — not only the medications to treat diabetes but the medications to treat hypoglycemia,” says Araque. She advises having extra glucagon or glucose tablets in case your blood sugar drops too low. People who take insulin should have backup insulin pens (or syringes and vials) if needed, and extra ketone strips.

“Contact your insurer or diabetes supplier about increasing your allotment of supplies,” advises Melissa Young, PharmD, CDCES, a pharmacist at University of Utah School of Medicine in Salt Lake City and a spokesperson for the Association of Diabetes Care and Education Specialists. “You do not want to run out of continuous glucose monitoring sensors or pump tubing. If your pump malfunctions, calling the manufacturer will usually be the first step. If a glucometer malfunctions, there is an 800 number on the back of the glucometer; try that first. Typically, manufacturer support is available to assist with glucometer questions.”

As for how much you should stock up on: The CDC recommends a 14-day self-quarantine period for anyone exposed to the coronavirus, starting from the date of last contact. “So to be safe, at least several weeks' to a month’s supply of medications on hand is recommended,” says Dr. Young.

RELATED: What to Pack in Your Diabetes Emergency Bag

4. Check for Measures That Make It Easier to Get Those Extra Supplies

If you are worried about the possibility that your prescription coverage won’t allow early refills, check with your pharmacy benefit provider or insurance provider. “Now that a national emergency has been declared, many insurers have increased allowances for [number of] days' supplies or early refills for chronic care, noncontrolled — such as nonopioid — medications for underlying medical conditions such as diabetes and high blood pressure,” says Young.

For instance, the large pharmacy benefit manager CVS Caremark announced on March 12, 2020, that it was working with its clients to waive early refill limits on 30-day prescription maintenance medication, and that Aetna would offer 90-day maintenance medication prescriptions for insured and Medicare members. The latest guidance on early refills and 90-day maintenance medication is in CVS Caremark’s FAQ.

Walgreens and CVS have also announced that they're waiving fees for home delivery of medication.

“Contact your regular pharmacy or diabetes supplier as soon as possible,” Young advises. “Your prescription information is on file, and they are aware of your insurance plan allowances on medications and supplies to be received per prescription.” Call the toll-free number on the back of your health insurance card for benefit details, she says. Take advantage of mail-order delivery if you are instructed to stay at home or are taking self-isolation measures.

If you are worried about the cost of extra medication and lack adequate coverage, check the JDRF resource page for help with diabetes medication costs. JDRF is a nonprofit dedicated to type 1 diabetes advocacy and research.

In general, know that several pharmaceutical companies have patient assistance programs (PAPs) that are designed to help people with diabetes better afford their insulin and oral medication. For example, Novo Nordisk and Dexcom have PAPs to serve individuals affected by job loss or insurance coverage related to COVID-19. Other pharmaceutical companies have existing PAPs that may help you in your specific situation. Ask your healthcare team if a PAP can help you better afford, and thus adhere to, your diabetes treatment plan.

RELATED: How Using Diabetes Patient Assistance Programs Can Help You Afford Insulin and Oral Meds

5. Don’t Worry Yet About the Medication or Insulin Supply Chain

You may be wondering if measures to slow the spread of the coronavirus that causes COVID-19 will affect your ability to get your medication and medical supplies on time.

As of August 26, a JDRF webpage on type 1 diabetes and COVID-19 stated that the organization is in touch with drug and diabetes supply manufacturers and is also unaware of any manufacturing or distribution disruptions. But "because of increased orders in recent weeks, some suppliers are telling [type 1 diabetes] customers that they may be delayed in immediately refilling orders. We are told that these are delays, not longer-term issues and not due to shortages in the supply chain," the JDRF says. They advise people to keep checking their page for the latest developments.

RELATED: What to Do if You Can’t Afford Your Insulin

6. Know That Some Over-the-Counter Medication Can Affect Blood Glucose

Some over-the-counter drugs used to treat cold and flu symptoms may affect your blood sugar levels, the JDRF warns. These include:

Cough syrups, except those that are labeled sugar-free

Pills that contain the same ingredients as syrups and do not have carbohydrates

Decongestants such as phenylephrine and pseudoephedrine

Aspirin in large doses

Advil (ibuprofen), which can increase the hypoglycemic effect of insulin

Ask your healthcare provider if you are not sure about the effects of an over-the-counter medication.

RELATED: 7 Common Meds That Can Make It Harder to Manage Your Blood Sugar

7. Be Vigilant for Signs of Unstable Blood Sugar or DKA, Especially if Insulin or Other Drugs Run Low

People with type 1 diabetes, and, in rare cases, long-standing type 2 diabetes, are vulnerable to developing a potentially life-threatening condition known as diabetic ketoacidosis (DKA), notes Araque. When the body doesn’t have enough insulin to convert glucose into energy, it begins to break down fat to use as fuel. The result is a buildup of acids in the bloodstream known as ketones.

As reported in the journal Diabetic Medicine in May, an “unusually high” number of COVID-19 hospitalized patients with diabetes in the United Kingdom developed DKA.

“We advise patients to check their ketones at home if they are experiencing persistent hyperglycemia to make sure they don’t go into DKA, regardless of whether they have any symptoms. This can happen in patients that miss injections or that have failures in their pumps or any problems getting access to insulin. They need to go to the hospital, separate of any symptoms of COVID-19.”

Given how the COVID-19 pandemic has changed daily life and increased stress for many people, you may also need to be checking your blood sugar more regularly, according to guidelines released by the JDRF–Beyond Type 1 Alliance. Ask your doctor about the right frequency for you.

8. Maintain a Healthy Lifestyle by Prioritizing Diet, Exercise, and Sleep

With gyms closed in a number of states and many sports activities postponed, it can be a challenge to stay on the healthy regimen you established before the pandemic. “In my experience, some patients become sedentary when they stay at home,” notes Araque. If you are not under quarantine or otherwise advised to stay at home, go for a walk outside in the park (while maintaining social distancing guidelines). If you are homebound, watch an exercise video or hit the Peloton. There are plenty of free resources to help you exercise online, as well. Also make sure you are stocking up on foods that help you consume carbohydrates in a healthy way, the JDRF advises.

Keeping an eye on weight gain is especially important if your BMI is 40 or higher. Researchers from Kaiser Permanente who looked at patient records within the hospital system reported in August that risk of death doubled for their COVID-19 patients who had a BMI of 40 to 44, and doubled again for those with a BMI of 45 and above.

By comparison, an individual who is 5 feet 5 inches tall and weighs 241 pounds would have a BMI of 40 and a person who is 6 feet tall and weighs 295 pounds would have the same BMI. The CDC has a BMI calculator to help you determine where you are.

Also per the JDRF, continue to manage stress and prioritize sleep — two other essentials for managing your blood sugar.

RELATED: 8 Healthy Carbs for People With Type 2 Diabetes

9. Lean on Peers With Diabetes for Support

In its guidelines, the JDRF–Beyond Type 1 Alliance recommends reaching out to others living with diabetes for support. "None of these behaviors are easy, and we all need support," the organizations comment in their guidelines.

A study published in October 2018 in Diabetes Care suggests that people with type 2 diabetes who participate in peer support programs are able to better manage depression and their blood sugar than those who don't. These results may lower overall healthcare costs, researchers say.

Meanwhile, participation in a diabetes online community is associated with increased self-care habits, notes a study published in July 2018 in Future Science OA. These habits include eating a healthy diet, exercising, and sticking to your medication regimen.

There are plenty of online resources for finding peer support, including Facebook groups and the ADA's peer support directory.

10. If You Call the Doctor, Keep Both COVID-19 and Diabetes in Mind

If you are sick, don't hesitate to reach out to your healthcare team, say the JDRF–Beyond Type 1 Alliance guidelines. But be sure to call first and have your health information ready.

“When people with diabetes call their doctor’s office for advice, they should be prepared to report blood sugar values, medication doses taken or missed, severity of respiratory symptoms, any nausea or vomiting, and how much they are able to eat or drink,” says Julie Adkison, PharmD, CDCES, a pharmacist and certified diabetes educator in Houston, who runs the blog My Diabetes Village. “Be aware of the signs and symptoms of DKA so that you know when to check for ketones, and seek care immediately if needed.”

And don’t be afraid to voice your concerns to your healthcare team. “This is not the time to not ask questions,” says Araque. “This is the time to ask questions and call your provider. It’s better to ask them than to delay care.”

For more information on how COVID-19 is affecting those living with diabetes, check out a study from Diabetes Daily.