Rapid Adoption of Telemedicine Along with Emergent Use of Continuous Glucose Monitors in the Ambulatory Care of Young Persons with New-Onset Type 1 Diabetes in the Time of COVID-19: A Case Series

Abstract

Aims:The COVID-19 pandemic has caused strain on hospital systems and potential delay in diagnosis of type 1 diabetes (T1D). Outpatient diagnosis and treatment of metabolically stable young persons with new-onset T1D have been shown to be equivalent to inpatient. We describe an approach to outpatient management of newly diagnosed T1D during the COVID-19 pandemic using an interdisciplinary team, telemedicine, and diabetes technologies including rapid implementation of continuous glucose monitoring (CGM).Methods:Following the onset of the COVID-19 pandemic, new-onset cases of T1D were tracked. After laboratory confirmation of diagnosis and metabolic stability, patients and families were referred for ambulatory initiation of insulin therapy and diabetes education. These cases were reviewed using data extracted from the electronic health record, comments from multidisciplinary team members, and cloud-based glucose data.Results:We report on seven young people with new-onset T1D without diabetic ketoacidosis from April to June 2020, during the COVID-19 pandemic. Ages ranged 9-23 years with presenting hemoglobin A1c (HbA1c) values 10-14.5%. Initial evaluation was generally face-to-face, followed by frequent telemedicine visits. Five patients had a family history of T1D. Two patients had access to at-home HbA1c kits prompting evaluation in the absence of symptoms. Four patients required emergency department evaluation. Five patients presented with ketosis. All patients were prescribed CGM at the first visit, most starting within 1 month.Conclusions:Technology is extraordinarily useful for the care of young persons with new-onset T1D in the ambulatory setting during the COVID-19 pandemic. Large observational studies are needed to better understand outcomes of an outpatient, technology-focused approach.

Keywords: COVID-19; continuous glucose monitoring; e-health; new-onset diabetes; pediatrics; sensor technology; telehealth; telemedicine; type 1 diabetes.

Fig. 1.

CGM tracings for diagnosis, 2 and 4 weeks for Case 1 (a) and Case 5 (b). Glucose values on y-axis are in mg/dL, time of day is on x-axis.

Fig. 2.

Timeline of CGM start from first visit. All patients were ordered CGM on day 0. Solid filled circle = day of first clinic appointment. Solid empty circle = day of CGM start. Dotted empty circle = day of CGM start, special case*. Solid line = pharmacy benefits. Dashed line = durable medical equipment order. *Patient started CGM on day 1 due to personal family device of Dexcom G6 CGM used temporarily until her own device could be obtained and family supply refilled accordingly. Prescription was sent that day and she received the device on day 19 from diagnosis. CGM, continuous glucose monitor.