An overview of COVID-19 in people with diabetes: Pathophysiology and considerations in the inpatient setting

Abstract

Introduction: The coronavirus disease (COVID-19) pandemic has continued to have a devastating impact on health worldwide. There has been a rapid evolution of evidence, establishing an increased risk of morbidity and mortality associated with diabetes and concurrent COVID-19. The objective of this review is to explore the current evidence for inpatient assessment and management of diabetes during the COVID-19 pandemic and highlight areas requiring further exploration.

Methods: A literature search of databases was conducted to November 2020 using variations on keywords SARS-CoV-2, COVID-19, SARS, MERS and diabetes. Information relating to the impact of diabetes on severity of COVID-19 infection, the impact of COVID-19 infection on diabetes management and diabetes-related complications was integrated to create a narrative review.

Discussion: People with diabetes and COVID-19 are at an increased risk of morbidity and mortality. It is important that people with both known and previously unrecognised diabetes and COVID-19 be promptly identified and assessed during acute illness, with close monitoring for clinical deterioration or complications. People with diabetes may require titration or alteration of their glycaemic management due to the potential for worse outcomes with hyperglycaemia and COVID-19 infection. Comprehensive discharge planning is vital to optimise ongoing glycaemic management.

Conclusion: Further understanding of the risk of adverse outcomes and optimisation of glycaemic management for people with diabetes during COVID-19 is required to improve outcomes. Increased glucose and ketone monitoring, substitution of insulin for some oral anti-hyperglycaemic medications and careful monitoring for complications of diabetes such as diabetic ketoacidosis should be considered.

Keywords: coronavirus disease; diabetes; severe acute respiratory syndrome coronavirus 2.

FIGURE 1

ACE2 and its role in the renin angiotensin system and SARS‐CoV‐2 infection. ACE2 is located on cell membranes and mediates entry of SARS‐COV‐2 through binding to spike glycoproteins resulting in endocytosis. This leads to downregulation of ACE2, which is required for cleaving of angiotensin II into angiotensin‐(1‐7) which exerts anti‐inflammatory vasoprotective effects. Angiotensin converting enzyme (ACE), angiotensin converting enzyme inhibitor (ACEi), angiotensin converting enzyme 2 (ACE2), AT1 angiotensin II receptor type 1 (AT1), Mas receptor (MasR)

FIGURE 2

The potential interplay of SARS‐CoV‐2 and diabetes. SARS‐CoV‐2 is characterized by a local and systemic immune response mediated by virus entry to cells via ACE2 (angiotensin converting enzyme 2) leading to multi‐organ inflammation. This response may be exacerbated by hyperglycaemia in patients with diabetes, affecting both the immune system and the inflammatory response