How to manage hypoglycemia (low blood sugar) in patients with COVID-19 (Coronavirus disease 2019)?

Managing Hypoglycemia in COVID-19 Patients

In COVID-19 patients with hypoglycemia, immediately treat with standard protocols (15-20g fast-acting carbohydrates if conscious, glucagon or IV dextrose if severe), then reduce insulin doses by 10-20% and closely monitor glucose every 2-4 hours, as both hypoglycemia and severe hyperglycemia are associated with increased mortality in this population. 1

Immediate Treatment of Hypoglycemia

• Administer 15-20 grams of fast-acting carbohydrates for conscious patients with blood glucose <70 mg/dL, or give glucagon/IV dextrose for severe hypoglycemia (<54 mg/dL) or altered mental status. 1

• Recheck blood glucose 15 minutes after treatment and repeat carbohydrate administration if still <70 mg/dL. 1

• Once blood glucose normalizes, provide a meal or snack containing complex carbohydrates and protein to prevent recurrence. 2

Critical Insulin Dose Adjustments

• Reduce insulin doses by 10-20% immediately after any hypoglycemic episode without clear precipitating cause. 1

• For patients at high risk (frail, elderly, acute kidney injury), use reduced starting insulin doses of 0.15 U/kg/day for basal alone or 0.3 U/kg/day total daily dose for basal-bolus regimens. 1

• Discontinue or withhold prandial insulin if patients have poor oral intake, as this is a major contributor to hypoglycemia in hospitalized COVID-19 patients. 1

Enhanced Glucose Monitoring Strategy

• Increase point-of-care glucose monitoring frequency to every 2-4 hours after hypoglycemia, particularly during afternoon, evening, and overnight periods when risk is highest. 1, 3

• Consider implementing continuous glucose monitoring (CGM) with remote monitoring capabilities to detect nocturnal and asymptomatic hypoglycemia, which has been shown to reduce recurrent hypoglycemia in hospitalized patients. 1

• If using CGM during COVID-19 hospitalization, validate sensor readings with point-of-care capillary glucose testing (sensor values should be within 20% of POC values for glucose >100 mg/dL). 1

COVID-19-Specific Risk Factors to Address

• Review all medications for hypoglycemia risk, particularly the combination of sulfonylureas with metformin (associated with 65.75% of hypoglycemia cases in COVID-19 patients) and insulin therapy (33.56% of cases). 4

• If hydroxychloroquine was added for COVID-19 treatment without adjusting diabetes medications, reduce antihyperglycemic agent doses by 20-30%, as HCQ increases hypoglycemia risk. 4

• Patients with hypertension (46.58% hypoglycemia risk), microvascular complications (33.56%), or macrovascular complications (23.29%) require more aggressive monitoring and lower insulin doses. 4

Target Glucose Range During COVID-19

• Maintain blood glucose targets of 140-180 mg/dL (7.8-10.0 mmol/L) for most hospitalized COVID-19 patients, as both hypoglycemia and severe hyperglycemia are associated with increased mortality. 1

• Avoid blood glucose <70 mg/dL and >180 mg/dL, as glucose dysregulation adversely affects mortality and hospital length of stay in COVID-19. 5

• For critically ill COVID-19 patients, a less stringent target of 7.8-13.9 mmol/L (140-250 mg/dL) may be appropriate to minimize hypoglycemia risk. 6

Medication Management Pitfalls

• Never use sliding scale insulin alone, as this increases both hypoglycemia and hyperglycemia risk and worsens hospital complications. 7

• Discontinue sulfonylureas in hospitalized COVID-19 patients and transition to basal-bolus insulin regimens, as sulfonylureas carry unacceptable hypoglycemia risk during acute illness. 1, 4

• Metformin should be held or used cautiously in COVID-19 patients with sepsis, shock, renal failure, or liver failure due to lactic acidosis risk. 1

Nutritional Considerations

• Ensure patients receive 150-200g of carbohydrate per day to prevent starvation ketosis, which can complicate glucose management. 2

• If oral intake is poor or inconsistent, reduce or eliminate prandial insulin and rely primarily on basal insulin with correction doses. 1

• For patients on parenteral nutrition with COVID-19, use continuous glucose monitoring to safely titrate insulin infusion and avoid hypoglycemia despite high insulin requirements. 8

Patient Education and Telemedicine Support

• Provide clear sick-day management instructions, emphasizing that insulin must be continued during COVID-19 illness but may need dose reduction. 2, 4

• Implement telemedicine follow-up within 24-48 hours of hypoglycemia to reassess insulin regimen and prevent recurrence. 4

• Educate patients to increase self-monitoring frequency to every 2-4 hours during acute illness and to contact providers for glucose <70 mg/dL or >250 mg/dL. 2