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The Science Behind COVID-19 and Type 2 Diabetes

March 20, 2020
May 6, 2020

With the US under a national emergency due to the pandemic caused by the novel coronavirus (which causes the disease called COVID-19), there is serious concern about what this means for people with high-risk conditions, such as diabetes and heart disease. If you or someone you care about is living with diabetes, you may have questions: Is the risk truly higher for patients with diabetes? Why might this be the case? What do the data say about this? 

Virta’s clinical team lays out what we know and what we don’t know from a scientific perspective.

Are people with chronic conditions at increased risk for COVID-19? 

The guidance from the Centers for Disease Control and Prevention (CDC) is that older people, and those living with chronic conditions such as diabetes, heart disease, and lung disease are at greater risk based on early data from China, where the disease was first reported. In addition, the World Health Organization (WHO) also lists high blood pressure and cancer as risk factors for COVID-19. 

We support guidelines from the CDC and the WHO recommending that anyone with chronic diseases should take social distancing and personal hygiene precautions very seriously during this time.

What do the data say regarding the impact of diabetes on COVID-19 cases seen so far?

COVID-19 appears to be similar to many other illnesses in which people with diabetes tend to have worse outcomes than people without diabetes. Based on early data from China, diabetes appears to be a risk factor for more severe lung complications [2,5] and death [1,2,4] related to COVID-19. Hyperglycemia at hospital admission is associated with greater risk of lung injury [3], but does not appear to be associated with greater risk of death [2,3].

Why are people with diabetes at higher risk?

Hyperglycemia impairs multiple branches of the immune system [5,6,7], and people with diabetes are predisposed to a wide variety of infections. [8] 

Is the immune dysfunction seen in diabetes and hyperglycemia responsible for the increased risk of complications and death in COVID-19, and does normoglycemia and reversed diabetes reduce the risk of complications and death? We do not know that diabetes and hyperglycemia are direct causes of poorer outcomes, and we cannot say that well-controlled or reversed diabetes confers protection. Given these limitations, we strongly advise our patients, even those doing very well from a diabetes standpoint, to follow all recommended precautions to avoid contact and prevent infection during the pandemic.  

For our part, we continue to support our patients in their quest for metabolic health through the Virta Treatment and acknowledge that there may be new challenges in the coming weeks to months in maintaining a stable low carb lifestyle. 

Is there any evidence to suggest a connection between ACE inhibitors, ARBs, and susceptibility to COVID-19? 

The coronavirus responsible for COVID-19 binds to human cells through a protein called angiotensin-converting enzyme 2 (ACE2) allowing the virus entry to the cell. [9] ACE inhibitors (ACE-i) and Angiotensin Receptor Blockers (ARBs) are widely prescribed for high blood pressure and for kidney protection in the setting of diabetes. Treatment with these meds increases the number of ACE2 proteins on the cell surface which has led to speculation that ACE-i and ARB drive the greater risk for complications in people with diabetes. [10] However, this remains a hypothesis that needs further validation from rigorous human studies. In the meantime, two animal studies have shown that these medications actually may be protective in the setting of coronavirus infection. [11,12]

Given this uncertain picture, we advise our patients to follow the recommendations of the European Society of Cardiology, and the Heart Failure Society of America/American College of Cardiology/American Heart Association that all medications for blood pressure should be continued at this time as there is not enough evidence to support stopping them or starting them due to coronavirus concerns.

What are the recommended anti-inflammatory medications for COVID-19 symptoms?

The World Health Organization (WHO) has not issued guidance against the use of ibuprofen (Motrin, Advil) for mild viral symptoms. 

The science on COVID-19 is evolving rapidly as researchers at the frontlines probe the novel coronavirus for an understanding of how it behaves, how it affects human health, and how to best fight it. At Virta, we will continue to monitor upcoming research and updated guidelines as they come and share what they might mean for people living with type 2 diabetes and other chronic conditions.

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Citations

  1. Fei Zhou et al, The Lancet, 2020,  https://doi.org/10.1016/S0140-6736(20)30566-3
  2. Chaomin Wu et al, JAMA Intern Med. 2020. doi:10.1001/jamainternmed.2020.0994
  3. Yang X, et al. Lancet Respir Med. 2020; https://doi.org/10.1016/S2213-2600(20)30079-5/
  4. Guan W et al. N Engl J Med. 2020; DOI:10.1056/NEJMoa2002032
  5. Geerlings SE, Hoepelman AI. FEMS Immunol Med Microbiol,1999; doi:10.1111/j.1574-695X.1999.tb01397.x
  6. Kiselar JG, et al. PLOS ONE, 2015; DOI: 10.1371/journal.pone.0130533
  7. Abu-Ashour W, et al. BMC Infect Dis. 2018;18(1):67. 2018 doi:10.1186/s12879-018-2975-2
  8. Weintrob et al. UpToDate, 2020; https://www.uptodate.com/contents/susceptibility-to-infections-in-persons-with-diabetes-mellitus
  9. Li, W. et al. Nature 426, 450–454 (2003). https://doi.org/10.1038/nature02145
  10. Fang, L et al. The Lancet Respiratory Medicine, 2020. https://doi.org/10.1016/S2213-2600(20)30116-8 
  11. Sun, M (2020). Chinese J of Tuberc & Resp Dis. 43. 219-222. 10.3760/cma.j.issn.1001-0939.2020.03.016. 
  12. Kuba, K. et al.Nat Med 11, 875–879 (2005). https://doi.org/10.1038/nm1267