What is the recommended treatment for a patient with COVID-19 and diabetes mellitus?

Management of COVID-19 in Patients with Diabetes Mellitus

Patients with diabetes who contract COVID-19 require intensive glycemic monitoring and medication adjustments to reduce mortality risk, with insulin being the preferred treatment during acute illness and careful management of other diabetes medications based on clinical status. 1

Risk Assessment and Monitoring

Diabetes significantly increases COVID-19 mortality risk (up to 50% higher) due to:

• Compromised innate immunity affecting phagocytosis and cell-mediated immunity 1
• Chronic inflammatory state that exacerbates COVID-19 cytokine storm 1
• ACE2 receptor dysregulation affecting viral entry and inflammatory response 1

Required Monitoring

• Blood glucose every 2-4 hours during acute illness 1
• Monitor for diabetic ketoacidosis (DKA), which occurs more frequently in COVID-19 patients 1
• Renal function monitoring due to high risk of acute kidney injury 1
• Prothrombin time before and during treatment 2
• Hepatic laboratory testing before and during treatment if using remdesivir 2

Medication Management Algorithm

1. Insulin Management

• Do not discontinue insulin therapy in any diabetic patient with COVID-19 1
• Expect significantly higher insulin requirements during COVID-19 infection 1
• For patients with severe illness:
  • Implement basal-bolus insulin regimen if total daily dose >0.6 U/kg 1
  • Consider continuous insulin infusion for severe hyperglycemia or DKA 1

2. Oral Antidiabetic Medications

• Discontinue the following medications during acute COVID-19 illness:

  • Metformin: Risk of lactic acidosis with dehydration 1
  • SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin): High risk of dehydration and euglycemic DKA 1
  • GLP-1 receptor agonists: Monitor closely if continued, risk of dehydration 1

• Medications that can be continued:

  • DPP-4 inhibitors (alogliptin, linagliptin, saxagliptin, sitagliptin): Generally well-tolerated during COVID-19 1

3. Antiviral Treatment

• Remdesivir is recommended for COVID-19 treatment in diabetic patients 2:
  • Adults and pediatric patients ≥40kg: 200mg IV loading dose on day 1, followed by 100mg IV daily
  • Treatment duration:
    • Non-hospitalized high-risk patients: 3 days
    • Hospitalized without mechanical ventilation: 5 days
    • Hospitalized with mechanical ventilation/ECMO: 10 days
  • Monitor for hepatic injury and infusion reactions 2

Special Considerations

Outpatient Management

• Implement telemedicine for regular monitoring 1
• Ensure adequate hydration (not exceeding 2L/day) 3
• Follow "sick day rules" with more frequent glucose monitoring 1
• Monitor for new-onset diabetes, which can be triggered by COVID-19 infection 4

Inpatient Management

• For mild hyperglycemia (BG <200 mg/dL): Consider low-dose basal insulin or correction doses 1
• For moderate hyperglycemia (BG 201-300 mg/dL): Basal insulin at 0.2-0.3 U/kg/day with correction doses 1
• For severe hyperglycemia (BG >300 mg/dL): Implement basal-bolus regimen 1

Common Pitfalls to Avoid

1. Failure to recognize DKA: COVID-19 can trigger severe DKA even with moderate hyperglycemia 1
2. Inappropriate continuation of SGLT2 inhibitors: These must be discontinued during acute illness 1
3. Inadequate insulin dosing: COVID-19 causes disproportionate insulin resistance compared to other critical illnesses 1
4. Missing new-onset diabetes: COVID-19 can induce new diabetes (prevalence 1.37%) through direct pancreatic β-cell damage 4
5. Overlooking medication interactions: Corticosteroids used for COVID-19 treatment can worsen hyperglycemia 5

By implementing this structured approach to managing COVID-19 in diabetic patients, clinicians can reduce the risk of complications and improve outcomes in this high-risk population.