Meta-analysis of T2D and COVID-19, Plus Practical Guidance on T2D Management

As our time with COVID-19 grows so does our understanding of the disease and its impact on different populations. Over the last four days alone, over 1000 articles have been published in the peer reviewed literature or posted as a preprint. Let’s take a look at some of the categories that are being discussed that pertain to metabolic disease.

Poor outcome rates and risk factors

ICU and ventilator mortality among critically ill adults with COVID-19

An encouraging report from preprint (not peer reviewed yet).

Data from 3 Emory Healthcare acute care hospitals was gathered from March 6th - April 17th on critically ill COVID patients who were admitted to the ICU. 165 out of  217 patients required mechanical ventilation (76%). Mortality in the ventilated patients was 29.7%. There were 98 (45.2%) females and the majority of patients were black (153 [70.5%]). Hypertension was the most common comorbid condition followed by diabetes (99, [45.6%]). Twenty-one patients (9.7%) had morbid obesity, with a body mass index (BMI) of 40 or greater. 16.6% were still on mechanical ventilation at the time of the report which will change the final assessment.

Diabetes mellitus is associated with increased mortality and severity of disease in COVID-19 pneumonia – A systematic review, meta-analysis, and meta-regression

Peer reviewed and published in Diabetes & Metabolic Syndrome: Clinical Research & Reviews

The outcome of interest in the review was composite poor outcome, including mortality, severe COVID-19, acute respiratory distress syndrome (ARDS), need for intensive care unit (ICU) care, and disease progression. There were a total of 6452 patients from 30 studies. The Forest-Plot below shows a clear association of diabetes with poor outcomes examined in multiple ways. Meta-regression showed that the association between DM and composite poor outcome was affected by age (p = 0.003) and hypertension (p < 0.001), but it was the opposite of what might be expected.  Having diabetes was a greater risk to patients who were young and without a diagnosis of hypertension.  Therefore, although the total risk of poor outcomes appears to be higher for older patients with diabetes and hypertension, diabetes as an individual risk factor is greater for those who are younger and those without hypertension.

Diabetes

Practical recommendations for the management of diabetes in patients with COVID-19

Peer reviewed and published in the Lancet Diabetes and Endocrinology. Review and recommendations.

Why is the risk of mortality from COVID-19 up to 50% higher in patients with a diagnosis of diabetes? Theories based on previous evidence discussed.

• Chronic hyperglycemia could help facilitate virus entry into cells. Additionally, it is possible that the virus is causing new onset diabetes by directly attacking the beta-cells of the pancreas causing insulin deficiency.  
• Discussion of the possible (stress the word possible as the opposite has also been discussed) that DPP4 blockade by DPP4 inhibitors could be helpful in COVID treatment.

Consensus recommendation for the treatment of diabetes from the group of authors:

Glycemic control as an important risk modifier was stressed.  Additionally, in patients without symptoms there is no need to change medications for hypertension or diabetes.  However, if a patient were to become sick, special precautions need to be taken to avoid dehydration which may mean discontinuing metformin, SGLT-2 inhibitors and GLP-1 agonists.