You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.
 

 

CME / ABIM MOC / CE

Glycemic Control for Patients With Diabetes and COVID-19

  • Authors: News Author: Miriam E. Tucker; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 6/5/2020
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 6/5/2021
Start Activity


Target Audience and Goal Statement

This article is intended for primary care physicians, endocrinologists, infectious disease specialists, critical care specialists, nurses, pharmacists, and other clinicians who care for patients at risk for coronavirus disease 2019 (COVID-19).

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Distinguish enzymes implicated in the pathophysiology of diabetes and COVID-19
  • Evaluate what is known about best practices in caring for patients with diabetes and COVID-19
  • Outline implications for the healthcare team


Disclosures

As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


News Author

  • Miriam E. Tucker

    Freelance writer, Medscape, LLC

    Disclosures

    Disclosure: Miriam E. Tucker has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD, FAAFP

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California

    Disclosures

    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Genentech; GlaxoSmithKline
    Served as a speaker or a member of a speakers bureau for: Shire

Editor/CME Reviewer

  • Esther Nyarko, PharmD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC, CHCP

    Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Disclosure: Amy Bernard, MS, BSN, RN-BC, CHCP, has disclosed no relevant financial relationships.

Medscape, LLC staff have disclosed that they have no relevant financial relationships.


Accreditation Statements



In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

    Contact This Provider

    For Nurses

  • Awarded 0.25 contact hour(s) of continuing nursing education for RNs and APNs; none of these credits is in the area of pharmacology.

    Contact This Provider

    For Pharmacists

  • Medscape, LLC designates this continuing education activity for 0.25 contact hour(s) (0.025 CEUs) (Universal Activity Number JA0007105-0000-20-088-H01-P).

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.

CME / ABIM MOC / CE

Glycemic Control for Patients With Diabetes and COVID-19

Authors: News Author: Miriam E. Tucker; CME Author: Charles P. Vega, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME / ABIM MOC / CE Released: 6/5/2020

Valid for credit through: 6/5/2021

processing....

Note: This is the twenty-ninth of a series of clinical briefs on the coronavirus outbreak. The information on this subject is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available.

Clinical Context

Diabetes is associated with deficits in humoral and cell-mediated immunity. It is linked to a higher risk for infection overall and greater severity of infection. The authors of the current recommendations noted that 20% of patients who develop severe pneumonia after a viral infection have diabetes.

The COVID-19 crisis has highlighted the increased risk for severe infections with diabetes. Diabetes has been associated with worse outcomes of infection, and specific mechanisms under investigation explain this relationship. First, angiotensin-converting enzyme 2 (ACE2) has been identified as the receptor for the coronavirus spike protein. Angiotensin-converting enzyme 2 has anti-inflammatory effects as well as effects in glucose metabolism. How COVID-19 upsets the balance and function of ACE2 remains largely unknown. The authors of the current recommendations noted that insulin resistance among patients with diabetes appears more severe with COVID-19 compared with other causes of critical illness. Patients with COVID-19 also seem to experience a disproportionate burden of diabetic ketoacidosis (DKA).

The dipeptidyl peptidase-4 (DPP4) enzyme, which is a treatment target in type 2 diabetes, was found to be the receptor for another coronavirus, which promoted Middle East respiratory syndrome (MERS). It is unclear if severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) follows this same pattern or how treatment with DPP4 inhibitors might affect infection with SARS-CoV-2.

The current guidelines by Bornstein and colleagues address the management of diabetes in the era of COVID-19.

Synopsis and Perspective

New guidance is available for managing inpatient hyperglycemia and DKA in patients with COVID-19 with diabetes using subcutaneous (SC) insulin. Bornstein and colleagues authored the new recommendations, which were published online April 23 in The Lancet Diabetes & Endocrinology.[1]

"The glycemic management of many COVID-19 positive patients with diabetes is proving extremely complex, with huge fluctuations in glucose control and the need for very high doses of insulin," according to a statement from Diabetes UK's National Diabetes Inpatient COVID Response Team.

"Intravenous [(IV)] infusion pumps, also required for inotropes, are at a premium and there may be the need to consider the use of [SC] or intramuscular insulin protocols," the team noted.

Updated as of May 20, all of the information of the National Diabetes Inpatient COVID Response Team is available on the Diabetes UK website.[2]

The new inpatient management graphic[3] adds more detail to the previous "front-door" guidance,[4] as reported by Medscape Medical News.

That document stressed that as well as identifying patients with known diabetes, it is imperative that all newly admitted patients with COVID-19 are evaluated for diabetes, as the SARS-CoV-2 infection is known to cause new-onset diabetes.

Subcutaneous Insulin Dosing

The new graphic[3] gives extensive details on SC insulin dosing in place of variable rate IV insulin when infusion pumps are not available and when the patient has a glucose level > 216 mg/dL but does not have DKA or hyperosmolar hyperglycemic state (HHS); however, the advice is not intended for people with COVID-19 causing severe insulin resistance in the intensive care unit.

The other new guidance graphic[5] on managing DKA or HHS in people with COVID-19 using SC insulin is also intended for situations where IV infusion isn't available.

Seek Help From Specialist Diabetes Team When Needed

Note: This is not to be used for mixed DKA/HHS or for patients who are pregnant, have severe metabolic derangement, other significant comorbidity, or impaired consciousness.

For those situations, the advice is to seek help from a specialist diabetes team, stated Diabetes UK.

Specialist teams will be available to answer diabetes queries, both by referring to relevant existing local documents and also by providing patient-specific advice.

Indeed, NHS England recommended that such a team be available in every hospital, with a lead consultant -- who must be free of other clinical duties at the time -- designated each day to coordinate these services. The role involves coordination of the whole service from the emergency department through to liaison with other specialties and managers.

Also newly updated is a page with extensive information for patients,[6] including advice for staying at home, medication use, self-isolating, shielding, hospital and doctor appointments, need for urgent medical guidance, and going to the hospital.

It also covers how COVID-19 can affect people with diabetes, especially with regard to children and school, pregnancy, work situations, and tips for picking up prescriptions.

The JDRF-Beyond Type 1 Alliance posted another shorter document with COVID-19 advice.[7]

The American Diabetes Association, Harvard Medical School, and the International Society for Pediatric and Adolescent Diabetes, in partnership with many other professional organizations, including the International Diabetes Federation, American Association of Clinical Endocrinologists, and Association of Diabetes Care & Education Specialists have all endorsed the recommendations.

The shorter document covers topics such as personal hygiene, distancing, diabetes management, and seeking treatment, as well as links to other resources on what to do when health insurance is lost and legal rights.

Highlights

  • The recommendations were developed by an expert panel from across Europe.
  • Outpatients with diabetes should continue to try to optimize glycemic control, with a target plasma glucose concentration of 72 to 144 mg/dL. In general, the target glycated hemoglobin (HbA1c) level for outpatients is < 7%.
  • In general, previous outpatient therapy for diabetes should be continued and refined through remote monitoring of plasma glucose levels and telemedicine.
  • Tighter glycemic control may improve patients’ risk of acquiring COVID-19. The recommendations also state that blood pressure and lipid control can reduce the impact of COVID-19.
  • Patients diagnosed with COVID-19 should be monitored for new-onset diabetes.
  • Although modulation of ACE2 is thought to influence infection rates and the severity of COVID-19, patients should generally continue treatment with ACE inhibitors and angiotensin receptor blockers (ARBs). This recommendation may change as new data emerge.
  • Likewise, statins should be continued during infection with SARS-CoV-2. Prompt discontinuation of statins might promote a cytokine storm among these patients.
  • Metformin and sodium-glucose cotransporter 2 (SGLT2) inhibitors may be continued among patients with mild COVID-19, but they should be held among patients with severe illness and dehydration because of the risks for lactic acidosis with metformin and DKA with SGLT2 inhibitors.
  • DPP4 inhibitors may be continued among patients with COVID-19.
  • Insulin therapy may also be continued among outpatients with less severe cases of COVID-19. Insulin needs may increase, so monitoring of blood glucose levels every 2 to 4 hours, or with a continuous glucose monitor, is recommended.
  • Patients with diabetes and concomitant fatty liver disease may be at particularly high risk for a cytokine storm and thus patients with COVID-19 should be closely monitored.
  • Obesity is a risk factor for ventilatory failure, and patients with diabetes and obesity may have a higher risk for intubation and ventilatory support.
  • Previously, severe acute respiratory syndrome coronavirus (SARS) was associated with long-term metabolic alterations among patients with severe infection. Survivors of severe COVID-19 should be monitored for the same.
  • Healthcare providers with diabetes should be kept away from frontline clinical duties if possible because of their increased health risks with COVID-19.
  • The authors recommended postponing bariatric surgery during the COVID-19 crisis because of potential risk for transmission in the operating room.

Clinical Implications

  • ACE2 has been particularly implicated in the pathophysiology of both diabetes and COVID-19.
  • The current recommendations state that ACE inhibitors, ARBs, DPP4 inhibitors, and statins can be continued among patients with diabetes and COVID-19; however, patients with severe SARS-CoV-2 infection should have metformin and SGLT2 inhibitors withheld.
  • Implications for the Healthcare Team: The current recommendations regarding the care of diabetes among patients with COVID-19 are reasonable, but they may change quickly as new data emerges. The healthcare team should follow a process for routine assessment of new information which might influence patient care.

Earn Credit

  • Print