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Steroids used in severe cases of COVID-19 can lead to new onset diabetes

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Dr V Mohan, Hinduja Foundation T1D program, Chairman & Chief of Diabetology, Dr Mohan’s Diabetes Specialities Centre, India speaks on the challenges in treating non-communicable diseases during a pandemic, why diabetes is a risk factor for severe COVID-19 and the transforming role of diabetologists in the current scenario, in an interview with Lakshmipriya Nair

How have the coronavirus lockdown and social distancing practices impacted diabetes management?

The lockdown has certainly impacted diabetes management in a big way. However, both positive and negative sides of the lockdown were seen. On the positive side, many of my patients, because of the fear that people with diabetes fare worse if they get COVID-19, started becoming very strict with their diet. They also started doing exercise indoors, to the extent possible. Many started doing yoga, meditation and pranayama. A significant number of patients increased the number of tests that they did with their glucometers and also took their medicines regularly. Many of them contacted us through phone for advice. With all this, I am happy to report that in a paper that we published in Diabetes Technology and Therapeutics, we actually reported an average reduction in the glycated haemoglobin test, (an index of 3 months control of diabetes), by 0.5 per cent in our patients. The lack of stress, lack of pollution, the non-accessibility of fast foods and reduction in smoking and alcohol because of sheer of non-availability of these, all helped during the lockdown.

On the other hand, there were a significant number of patients in whom the lockdown impacted their diabetes badly because they were not able to go out for walks and they did not have any facility in their own homes for exercise. Also, their diet also went haywire because they were not able to get fresh vegetables and fruits regularly. Hence they started consuming more rice and other carbohydrates. Added to this were the stress factor, anxiety and depression. All these led to weight gain and to uncontrolled diabetes. Many of them did not even come for their check-up when it was absolutely needed. Unfortunately, some of our patients with a foot infection, who should have been rushed to the hospital, delayed their visit by weeks because of the fear of COVID-19 and due to the lockdown. This resulted in unfortunate amputations which could have been avoided. In summary, I would say the lockdown has had both positive and negative impacts.

How has the role of diabetologists transformed since the onset of the pandemic?

On March 25, 2020, the Government of India legalised telemedicine and laid down the guidelines for doing teleconsultations. Diabetology is one speciality where through telemedicine doctors can offer consultation and advise to their patients. We saw a significant increase in the telemedicine consultations by diabetologists and during the lockdown virtual consultations became the norm. More recently, due to the use of steroids, there has been a huge increase in the diabetes rate and worsening of diabetes and hence the role of diabetologists became even more important.

What are the factors that increase the risk of complications and fatality for diabetic patients who contract COVID-19 infection?

In people with uncontrolled diabetes, the body’s immunity is affected. Due to the poor immunity, when the coronavirus enters into the body, the body is not able to resist and fight the COVID-19 infection as well as in those without diabetes. This eventually leads to what is called as a hyperinflammatory response also known as ‘cytokine storm’. This results in the release of several harmful cytokines and inflammatory chemicals in the body leading to multi-organ damage which is the reason why severe lung damage, heart damage and acute kidney and liver damage has been reported in people with diabetes, resulting in fatality. Sometimes the marked increase in sugar levels can lead to diabetic ketoacidosis.

Tell us more about the new evidence and protocols emerging about the management of diabetes in COVID-19 patients?

Basically, the treatment of diabetes has not changed, but intensification of the treatment is what has occurred. In those with mild diabetes as well as mild COVID-19, nothing has changed and patients continue the same medications that they are on. However, if either the diabetes is severe or if the COVID-19 infection is severe and the patients have to be admitted, they have to be started on insulin which is often given several times a day. This is further complicated by the fact that steroids are used in the severe cases of COVID-19 which means that the sugar levels can shoot up necessitating a higher dose of both antidiabetic drugs as well as insulin.

Are there any therapies/drugs emerging for the standard of care for diabetic patients who are undergoing treatment for COVID-19? 

There are no new drugs, but the intensification of the treatments that the patients are already on, is being seen for the treatment for COVID-19.

Is there new-onset diabetes due to COVID-19? If yes, what are the causes?

The new onset of diabetes due to COVID-19 can be due to several reasons.

  • Due to stress, anxiety, depression, people can get precipitation of new onset of diabetes.
  • Weight gain, due to an unhealthy diet and lack of exercise can also precipitate diabetes.
  • The use of steroids, especially the large doses of dexamethasone which is used in severe cases of COVID-19 can lead to new onset diabetes and also to an acute exacerbation of mild diabetes, if present.
  • There is an entity called ‘Covid induced diabetes’. It is believed that the pancreatic β cells can be directly damaged by the coronavirus, although the exact proof for this is still lacking.

What can be the role of a diabetologist in post-COVID-19-care strategy? 

What COVID-19 has taught everyone is the need for good control of diabetes. Therefore, the diabetologist must spread awareness about how to achieve good diabetes control.  This will help to prevent, not only COVID related complications but also the complications of diabetes in general like diabetic eye disease, kidney disease, heart disease, nerve complications etc. Hence, more emphasis on educating diabetic patients and spreading awareness about diabetes and the consequences of poor control of diabetes is urgently needed.

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