Tuesday, March 28, 2023
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Health Sciences Clinical Professor of Family Medicine
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Health Sciences Clinical Professor of Family Medicine
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CME / ABIM MOC / CE Released: 3/17/2023
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One of the many startling revelations regarding infection with SARS-CoV-2 was the effect of infection on glucose metabolism. Early in the pandemic, clinicians were unprepared for the serious hyperglycemia associated with COVID-19. Moreover, data emerged that COVID-19 was a risk factor for incident diabetes. A previous systematic review and meta-analysis by Zhang and colleagues, published in the November 15, 2022, issue of BMC Medicine, assessed this issue.[1]
Researchers focused on the results of 9 studies, which included nearly 40 million participants. The incidence of diabetes after COVID-19 was 15.53 cases per 1000 person-years, and the odds ratio for diabetes after COVID-19 was 1.62 (95% CI, 1.45-1.80). COVID-19 was associated with significant increases in the risk for both type 1 and type 2 diabetes, and it was associated with a higher risk for diabetes among children and adolescents, young and middle-aged adults, and older adults. Finally, more severe COVID-19 infections were associated with an even higher risk for diabetes.
The Omicron variant of SARS-CoV-2 has generally been associated with less severe infections. Does it still carry a higher risk for diabetes? The current study addresses this question.
The increased risk for diabetes after COVID-19 infection has persisted into the Omicron era, but vaccination against SARS-CoV-2 appears to diminish that likelihood, new data suggest.
The findings, from more than 20,000 patients in the Cedars-Sinai Health System in Los Angeles, California, suggest that “continued efforts to prevent COVID-19 infection may be beneficial to patient health until we develop better understanding of the effects of potential long-term effects of COVID-19,” lead author Alan C. Kwan, MD, from the Department of Cardiology at Cedars Sinai’s Smidt Heart Institute, told Medscape Medical News.
Several studies conducted early in the pandemic suggested increased risks for both new-onset diabetes and cardiometabolic diseases after COVID-19 infection, possibly as a result of persistent inflammation contributing to insulin resistance.[2,3]
However, it has not been clear whether those risks have persisted with the more recent predominance of the less-virulent Omicron variant or whether the COVID-19 vaccine influences the risk. This new study suggests that both are the case.
“Our results verify that the risk of developing type 2 diabetes after a COVID-19 infection was not just an early observation but, in fact, a real risk that has, unfortunately, persisted through the Omicron era,” Dr Kwan noted.
“While the level of evidence by our study and others may not reach the degree needed to affect formal guidelines at this time, we believe it is reasonable to have increased clinical suspicion for diabetes after COVID-19 infection and a lower threshold for testing,” he added.
Moreover, “We believe that our study and others suggest the potential role of COVID-19 to affect cardiovascular risk, and so both prevention of COVID-19 infection, though reasonable personal practices and vaccination, and an increased attention to cardiovascular health after COVID-19 infection is warranted.”
The findings were published online February 14 in JAMA Network Open.[4]
Diabetes Risk After COVID-19 Persists, Lower With Vaccination
Dr Kwan and colleagues analyzed data for a total of 23,709 patients treated (inpatient and outpatient) for at least 1 COVID-19 infection between March 2020 and June 2022.
Rates of new-onset diabetes (using International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, codes primarily type 2 diabetes), hypertension, and hyperlipidemia were all elevated in the 90 days after COVID-19 infection compared with the 90 days prior. The same was true of 2 diagnoses unrelated to COVID-19: urinary tract infection and gastroesophageal reflux, used as benchmarks of healthcare engagement.
The highest odds for post versus pre infection were for diabetes (odds ratio [OR], 2.35; P<.001), followed by hypertension (OR, 1.54; P<.001), the benchmark diagnoses (OR, 1.42; P<.001), and hyperlipidemia (OR, 1.22; P=.03).
After adjustments, the risk versus the benchmark conditions for new-onset diabetes before versus after COVID-19 was significantly elevated (OR, 1.58; P<.001), whereas the risks for hypertension and hyperlipidemia versus benchmark diagnoses were not (OR, 1.06 [P=.52] and 0.91 [P=.43], respectively).
The diabetes risk after versus before COVID-19 infection was higher among those who had not been vaccinated (OR, 1.78; P<.001) compared with those who had received the vaccine (OR, 1.07; P=.80).
However, there was no significant interaction between vaccination and diabetes diagnosis (P=.08). “For this reason, we believe our data are suggestive of a protective effect in the population who received vaccination prior to infection, but [this is] not definitive,” Dr Kwan said.
There were no apparent interactions by age, sex, or preexisting cardiovascular risk factors, including hypertension or hyperlipidemia. Age, sex, and timing of index infection regarding the Omicron variant were not associated with an increased risk for a new cardiometabolic diagnosis before or after COVID-19 infection in any of the models.
Dr Kwan told Medscape Medical News: “We have continued to be surprised by the evolving understanding of the SARS-Cov-2 virus and the effects on human health. In the beginning of the pandemic it was framed as a purely respiratory virus, which we now know to be a severely limited description of all of its potential effects on the human body. We believe that our research and others raise a concern for increased cardiometabolic risk after COVID infection.”
He added, “while knowledge is incomplete on this topic, we believe that clinical providers may wish to have a higher degree of suspicion for both diabetes and risk of future cardiac events in patients after COVID infection, and that continued efforts to prevent COVID infection may be beneficial to patient health until we develop better understanding of the effects of potential long-term effects of COVID.”
This study was funded by the Erika J. Glazer Family Foundation, the Doris Duke Charitable Foundation, and grants from the National Institutes of Health. Dr Kwan has reported receiving grants from the Doris Duke Charitable Foundation during the conduct of the study.
JAMA Netw Open. Published online February 14, 2023.
