Practical Recommendations for Managing Type 2 Diabetes During the COVID-19 Pandemic

Shelly A. Im, MD, is a board-certified endocrinologist with Westmed Medical Group in Westchester County, New York. Dr Im has also served as assistant professor and medical director of the Diabetes Alliance at Mount Sinai Hospital in New York City. Within her general endocrinology practice, she maintains a clinical focus on diabetes mellitus, thyroid disorders, thyroid cancer, and osteoporosis.

Since the COVID-19 pandemic was declared, have you encountered problems with availability of insulin and supplies for glucose monitoring? If so, how have you adjusted treatment protocols to account for temporary shortages?

As a result of the COVID-19 public health emergency declaration, Medicare has loosened guidelines for the acquisition of continuous glucose monitoring (CGM) and glucometer testing supplies during the pandemic.¹ Medicare allows providers to offer self-management training services through a telehealth platform. Medicare is collaborating with the American Diabetes Association to prevent potential gaps in healthcare coverage for patients who lost their insurance due to unemployment, reduce the prescription copay for insulin, and increase COVID-19 testing accessibility.

Although CGM is not yet approved for use in the hospital setting, there might be a role for it during the pandemic in terms of reducing exposure time and the use of personal protective equipment (PPE), while optimizing glucose control and potentially improving health outcomes related to COVID-19 infection.

How can you manage lifestyle effects on the blood glucose level during lockdown, as patients are less physically active and prone to snacking?

A: Lifestyle interventions are especially crucial during the pandemic for optimal diabetes management and to prevent disease progression, morbidity, and mortality. The shutdown of restaurants and indoor dining can, potentially, encourage better eating habits, such as cooking at home, eating smaller portions, and monitoring carbohydrate intake by reading nutrition labels. The shutdown of gyms and exercise facilities can be addressed by increasing outdoor physical activities, encouraging step-counting to gauge activity level, and using at-home exercise programs or equipment, when possible. Social and physical isolation can lead to depression, which can also affect lifestyle modifications and glycemic control, and is therefore an important problem to address.

How do you address anxiety in patients with diabetes in the face of emerging evidence that they are in a higher-risk group?

A. Data do indicate that having diabetes and then being infected with COVID-19 is associated with worse outcomes, including increased mortality, severity of illness, and frequency of respiratory distress.² The best way to reduce anxiety is to practice social distancing and maintain proper use of PPE to avoid being infected with COVID-19, and to get the COVID-19 vaccine as soon as it becomes available to you.

Has testing shown a change in diabetes control as reflected by hemoglobin A_1c [HbA_1c] values? How are you managing trends?

A. Information regarding diabetes control during the pandemic is limited. Most of the data collected are based largely on hospitalized patients. Many patients have deferred their HbA_1c testing and preventive care visits and curtailed urgent care and emergency department visits because of social distance recommendations and the risk of exposure to SARS-CoV-2. However, guidelines for optimal glycemic control apply to all patients who have a diagnosis of type 2 diabetes, regardless of their COVID-19 status.

Have you introduced new therapies, including insulin and glucagon-like peptide-1 receptor agonists, to prevent glucose variability and prevent poor COVID-19 outcomes?

A: Adding new therapies to improve glycemic control during the pandemic is beneficial if doing so reduces poor outcomes in terms of COVID-19 infection. One class of diabetes medication, the dipeptidyl peptidase-4 inhibitors, is being studied as a potential treatment for COVID-19.⁴

Maintaining patients on their normal treatment regimen has been encouraging during the pandemic, even if they are infected with COVID-19. Consider adjusting certain medications in the setting of reduced oral intake or dehydration, especially in hospitalized patients. Short-term insulin therapy can be useful for managing hyperglycemia.

Now that you are engaging in more virtual visits, what do you recommend for improving the value of telehealth appointments for these patients? Do you see benefit in continued telehealth for this population after the pandemic?

A. Telehealth is a valuable tool for patients who aim to minimize their exposure to SARS-CoV-2 and can be useful after the pandemic for elderly or immobile patients who have difficulty traveling to a physician’s office. Telehealth can also serve an alternative means of care during natural disasters and weather emergencies.

To make the most of a telehealth visit, I recommend that:

• Patients have tools to collect data at home, including an ambulatory blood pressure cuff, pulse oximeter, scale, and glucometer or CGM device; and
• Patients should have their blood and urine tests completed prior to the virtual visit, with specimens drawn at a lab or at home.

When any of your patients with type 2 diabetes developed COVID-19, what variables led to better outcomes?

A. Studies show that patients with well-controlled diabetes have better outcomes than patients with poor glucose control. These include reduction in medication use (antibiotics, steroids, and pressor agents), the intubation rate, the use of extracorporeal membrane oxygenation, the rate of complications (acute respiratory distress syndrome, kidney failure, and septic shock), and mortality.⁵ Other variables that influence outcomes include age, obesity, and comorbidities.

Are there treatment protocols that you have found to be ineffective or harmful when any of your patients with type 2 diabetes contracted COVID-19?

A. Yes. First, withholding angiotensin-converting enzyme inhibitors and angiotensin receptor blockers has not been shown to reduce mortality, hospitalizations, or the severity of COVID-19 infection in patients with diabetes and hypertension.⁶
 
Second, because hydroxychloroquine has been associated with the risk of hypoglycemia in patients who have or do not have diabetes, diabetes regimens for hospitalized patients receiving hydroxychloroquine to treat COVID-19 might need to be modified.

Are there new testing or screening protocols that might be useful for clinicians to know about?

A. First, patients hospitalized with COVID-19 who do not have a history of diabetes might present with hyperglycemia, so glucose monitoring in all hospitalized COVID-19 patients is important.
 
Second, monitoring ketones in this setting is helpful to rule out potentially dangerous complications, such as diabetic ketoacidosis, and to influence the management of hyperglycemia.

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