Coronavirus disease 2019 (COVID-19) caused by the novel severe acute respiratory syndrome (SARS-CoV-2) virus is a rapidly progressing pandemic with more than 2.5 million infected cases worldwide and WHO estimated mortality rate of 6.9% at the time of writing. As clinicians, it is imperative that we keep ourselves informed of the daily emerging scientific evidence in order to understand the impact of COVID-19 on our patients, particularly those belonging to a high-risk group, such as the diabetic population.
Although the evidence to date have shown that children are generally less prone to COVID-19 infection with those infected tending to have a milder disease course, children with existing comorbidities continue to remain highlighted as at risk group.1x[1]Ludvigsson JF. Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults. Acta paediatrica (Oslo, Norway : 1992). 2020.
Google ScholarSee all References A report released by the International Society of Pediatric and Adolescent Diabetes (ISPAD) dated 25th March 2020 reassuringly stated that there were no cases of COVID-19 in diabetic children or adolescents who had required hospitalization. Although it seems that children with diabetes have not shown a different disease pattern compared with their non-diabetic counterparts, clinicians caring for diabetic children should not become complacent, particularly in these early days when new evidence is still emerging. We continue to recommend a cautious approach in the management strategies for children with diabetes, as individuals with underlying diabetes are at increased risk of severe pulmonary infections, and diabetes was found to be a risk factor for mortality in patients infected with severe acute respiratory syndrome (SARS-CoV-1) and Middle East Respiratory Syndrome coronavirus (MERS-CoV).2x[2]Song, Z., Xu, Y., Bao, L., Zhang, L., Yu, P., Qu, Y. et al. From SARS to MERS, Thrusting Coronaviruses into the Spotlight. Viruses. 2019;
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The main strategy in reducing the risk and severity of the SARS-CoV-2 infection in diabetic children is to optimize glycemic control. In addition, the general recommendations for infection prevention cannot be emphasized enough during this pandemic. All diabetic patients should receive pneumococcal and influenza vaccinations and be specifically reminded about the importance of good hand hygiene, avoiding touching their faces, and observing appropriate social distancing to reduce risk of infection. We echo the specific recommendations outlined by Gupta et al for diabetic patients infected with SARS-CoV-2.3x[3]Gupta, R., Ghosh, A., Singh, A.K., and Misra, A. Clinical considerations for patients with diabetes in times of COVID-19 epidemic. Diabetes & metabolic syndrome. 2020;
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Crossref | Scopus (16) | Google ScholarSee all References Specifically, those with type 1 diabetes should adhere to standard “sick day” guidelines with increased frequency of monitoring of blood glucose and ketones. In addition, frequent changes in dosage and correction in insulin boluses may be required to maintain normoglycemia. In ill patients with type 2 diabetes, dosage of oral anti-diabetic drugs such as metformin need to be adjusted to reduce the risk of lactic acidosis.
Notably, diabetologists should pay attention to recent reports on the use of angiotensin converting enzyme (ACE)-inhibiting agents in patients with COVID-19, as many diabetic patients including children are receiving this medication for albuminuria. Although there is some suggestion that ACE-inhibitors may increase the severity of COVID-19, reports are conflicting suggesting both increased ACE level may be a poor prognostic factor for severe pneumonia and that use of ACE-inhibiting agents reduce the severity of pulmonary inflammation.4x[4]Bavishi, C., Maddox, T.M., and Messerli, F.H. Coronavirus Disease 2019 (COVID-19) Infection and Renin Angiotensin System Blockers. JAMA cardiology. 2020;
Crossref | Scopus (2) | Google ScholarSee all References The evidence has not been sufficient to change the practice for patients with diabetes thus far, but the endocrine community should remain vigilant for new evidence and guidance as more information on this issue emerges. On a similar note, there is some suggestion that ibuprofen may increase expression of ACE-2 receptor, potentially increasing binding of the virus to target cells and potentiating the SARS-CoV-2 infection.5x[5]Sodhi, M. and Etminan, M. Safety of Ibuprofen in Patients With COVID-19: Causal or Confounded?. Chest. 2020;
Abstract | Full Text | Full Text PDF | Google ScholarSee all References Although this theoretical concern requires further substantiation, the advice from the WHO is to use paracetamol over non-steroidal anti-inflammatory agents for the treatment of fever associated with COVID-19 which is prudent. 5x[5]Sodhi, M. and Etminan, M. Safety of Ibuprofen in Patients With COVID-19: Causal or Confounded?. Chest. 2020;
Abstract | Full Text | Full Text PDF | Google ScholarSee all References
It is important for clinicians to be cognizant of the possibility of delayed presentation of new cases of type 1 diabetes, as parents may delay medical attention for their children due to fear of exposure to infection in emergency services. Moreover, parents of children with suboptimal diabetic control who require closer follow up may postpone their appointments due to fear and anxiety. Where available, these patients should be offered the option of remote teleconsultation with their doctors to review their glycemic control and insulin titration, especially for young children. With many countries instituting policies to mandate home quarantine, clinicians also should be mindful of the potential of changes in dietary habits and available food choices as well as reduction in physical activity, which impact glycemic control.
There has been advancement in technologies now available commercially to aide diabetes management including telehealth monitoring technologies, diagnostic tools, and monitoring kits. Amidst this COVID-19 crisis, endocrinologists can exploit these systems and devices to provide remote care to their patients with diabetes. The use of continuous glucose monitoring systems (CGMS) is now the standard of care in many centers worldwide. Closed-loop CGMS systems that incorporate the use of automated decision support systems between insulin pumps and CGMS provide an added benefit, which is that insulin titration can be achieved accurately with good comparability to endocrinologist-decision making.6x[6]Nimri, R., Dassau, E., Segall, T., Muller, I., Bratina, N., Kordonouri, O. et al. Adjusting insulin doses in patients with type 1 diabetes who use insulin pump and continuous glucose monitoring: Variations among countries and physicians. Diabetes, obesity & metabolism. 2018;
20: 2458–2466
Crossref | Scopus (8) | Google ScholarSee all References This can reduce the need for intensive physician monitoring.6x[6]Nimri, R., Dassau, E., Segall, T., Muller, I., Bratina, N., Kordonouri, O. et al. Adjusting insulin doses in patients with type 1 diabetes who use insulin pump and continuous glucose monitoring: Variations among countries and physicians. Diabetes, obesity & metabolism. 2018;
20: 2458–2466
Crossref | Scopus (8) | Google ScholarSee all References Home testing of glycated hemoglobin (HbA1c) will be welcomed by diabetics and their endocrinologists in the face of the COVID-19 crisis. Possibilities exist for home HbA1c testing in which patients need only perform finger-prick sampling similar to a standard blood glucose monitoring procedure. HbA1c readings from finger-prick samples have been shown to agree favorably with gold standard assays using venepuncture samples.7x[7]Hall, J.M., Fowler, C.F., Barrett, F., Humphry, R.W., Van Drimmelen, M., and MacRury, S.M. HbA1c determination from HemaSpot blood collection devices: comparison of home prepared dried blood spots with standard venous blood analysis. Diabetic medicine : a journal of the British Diabetic Association. 2019;
Crossref | Scopus (2) | Google ScholarSee all References Collected samples can be submitted via postal mail and assay has been shown to remain accurate up to 4 days post-collection, a feature that can be exploited during a pandemic such as this.7x[7]Hall, J.M., Fowler, C.F., Barrett, F., Humphry, R.W., Van Drimmelen, M., and MacRury, S.M. HbA1c determination from HemaSpot blood collection devices: comparison of home prepared dried blood spots with standard venous blood analysis. Diabetic medicine : a journal of the British Diabetic Association. 2019;
Crossref | Scopus (2) | Google ScholarSee all References In addition, state-of-the-art technology for screening complications, such as the hand-held non-mydriatic portable fundus camera linked to a smartphone, has been shown to be reliable for diabetic retinopathy screening.8x[8]Jin, K., Lu, H., Su, Z., Cheng, C., Ye, J., and Qian, D. Telemedicine screening of retinal diseases with a handheld portable non-mydriatic fundus camera. BMC Ophthalmology. 2017;
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Crossref | Scopus (14) | Google ScholarSee all References “Use of such technology potentially could reduce in person visits for ophthalmologic care and can be implemented easily and with reasonable reliability at least for use during this pandemic. These remote consulting and prescribing services should be made possible through the establishment of telehealth consultation systems. Importantly, although these services should keep patients safe and lighten the ambulatory aspect of diabetes care, families must be made aware they do not replace emergency care, especially if the child is unwell, in which case, a visit to the nearest acute care center would be strongly advised.
Although we are learning more about SARS-CoV-2 by the day, there remain many grey areas and uncovered blind spots, some of which may apply to diabetic children. It is essential that we keep ourselves updated on the continuous stream of information that may concern our patients. As healthcare providers caring for these vulnerable patients, our role and commitment to them remains unbroken. We should continue to provide diabetes care through the safest possible way, and remain accessible to our patients, either through telehealth platforms or specifically planned face-to-face visits that would incorporate measures to minimize risk of infection to the patients and the healthcare team.
