Practical recommendations for the management of diabetes in patients with COVID-19
Identifieur interne : 000957 ( Pmc/Corpus ); précédent : 000956; suivant : 000958Practical recommendations for the management of diabetes in patients with COVID-19
Auteurs : Stefan R. Bornstein ; Francesco Rubino ; Kamlesh Khunti ; Geltrude Mingrone ; David Hopkins ; Andreas L. Birkenfeld ; Bernhard Boehm ; Stephanie Amiel ; Richard Ig Holt ; Jay S. Skyler ; J Hans Devries ; Eric Renard ; Robert H. Eckel ; Paul Zimmet ; Kurt George Alberti ; Josep Vidal ; Bruno Geloneze ; Juliana C. Chan ; Linong Ji ; Barbara LudwigSource :
- The Lancet. Diabetes & Endocrinology [ 2213-8587 ] ; 2020.
Abstract
Diabetes is one of the most important comorbidities linked to the severity of all three known human pathogenic coronavirus infections, including severe acute respiratory syndrome coronavirus 2. Patients with diabetes have an increased risk of severe complications including Adult Respiratory Distress Syndrome and multi-organ failure. Depending on the global region, 20–50% of patients in the coronavirus disease 2019 (COVID-19) pandemic had diabetes. Given the importance of the link between COVID-19 and diabetes, we have formed an international panel of experts in the field of diabetes and endocrinology to provide some guidance and practical recommendations for the management of diabetes during the pandemic. We aim to briefly provide insight into potential mechanistic links between the novel coronavirus infection and diabetes, present practical management recommendations, and elaborate on the differential needs of several patient groups.
Url:
DOI: 10.1016/S2213-8587(20)30152-2
PubMed: 32334646
PubMed Central: 7180013
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PMC:7180013Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Practical recommendations for the management of diabetes in patients with COVID-19</title><author><name sortKey="Bornstein, Stefan R" sort="Bornstein, Stefan R" uniqKey="Bornstein S" first="Stefan R" last="Bornstein">Stefan R. Bornstein</name><affiliation><nlm:aff id="aff1">Department of Medicine III, University Hospital Carl Gustav Carus, Dresden, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Paul Langerhans Institute Dresden of the Helmholtz Center Munich, University Hospital Carl Gustav Carus, Dresden, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff3">Department of Diabetes, School of Life Course Science and Medicine, King's College London, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="aff4">Department of Endocrinology and Diabetology, University Hospital Zurich, Zurich, Switzerland</nlm:aff></affiliation><affiliation><nlm:aff id="aff5">Faculty of Medicine, Technische Universität Dresden, Dresden, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff7">German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany</nlm:aff></affiliation></author><author><name sortKey="Rubino, Francesco" sort="Rubino, Francesco" uniqKey="Rubino F" first="Francesco" last="Rubino">Francesco Rubino</name><affiliation><nlm:aff id="aff3">Department of Diabetes, School of Life Course Science and Medicine, King's College London, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="aff8">Bariatric and Metabolic Surgery, King's College Hospital, London, UK</nlm:aff></affiliation></author><author><name sortKey="Khunti, Kamlesh" sort="Khunti, Kamlesh" uniqKey="Khunti K" first="Kamlesh" last="Khunti">Kamlesh Khunti</name><affiliation><nlm:aff id="aff9">Diabetes Research Centre, University of Leicester, Leicester, UK</nlm:aff></affiliation></author><author><name sortKey="Mingrone, Geltrude" sort="Mingrone, Geltrude" uniqKey="Mingrone G" first="Geltrude" last="Mingrone">Geltrude Mingrone</name><affiliation><nlm:aff id="aff3">Department of Diabetes, School of Life Course Science and Medicine, King's College London, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="aff10">Fondazione Policlinico Universitario Agostino Gemelli Istituto Di Ricovero e Cura a Carattere Scientifico, Rome, Italy</nlm:aff></affiliation><affiliation><nlm:aff id="aff11">Department of Internal Medicine, Università Cattolica del Sacro Cuore, Rome, Italy</nlm:aff></affiliation></author><author><name sortKey="Hopkins, David" sort="Hopkins, David" uniqKey="Hopkins D" first="David" last="Hopkins">David Hopkins</name><affiliation><nlm:aff id="aff3">Department of Diabetes, School of Life Course Science and Medicine, King's College London, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="aff12">Institute of Diabetes Endocrinology and Obesity, King's Health Partners, London, UK</nlm:aff></affiliation></author><author><name sortKey="Birkenfeld, Andreas L" sort="Birkenfeld, Andreas L" uniqKey="Birkenfeld A" first="Andreas L" last="Birkenfeld">Andreas L. Birkenfeld</name><affiliation><nlm:aff id="aff3">Department of Diabetes, School of Life Course Science and Medicine, King's College London, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="aff7">German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff13">Department of Diabetology, Endocrinology and Nephrology, University Hospital Tübingen, Tübingen, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff14">Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany</nlm:aff></affiliation></author><author><name sortKey="Boehm, Bernhard" sort="Boehm, Bernhard" uniqKey="Boehm B" first="Bernhard" last="Boehm">Bernhard Boehm</name><affiliation><nlm:aff id="aff15">Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore</nlm:aff></affiliation><affiliation><nlm:aff id="aff16">Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore</nlm:aff></affiliation></author><author><name sortKey="Amiel, Stephanie" sort="Amiel, Stephanie" uniqKey="Amiel S" first="Stephanie" last="Amiel">Stephanie Amiel</name><affiliation><nlm:aff id="aff3">Department of Diabetes, School of Life Course Science and Medicine, King's College London, London, UK</nlm:aff></affiliation></author><author><name sortKey="Holt, Richard Ig" sort="Holt, Richard Ig" uniqKey="Holt R" first="Richard Ig" last="Holt">Richard Ig Holt</name><affiliation><nlm:aff id="aff17">Human Development and Health, Faculty of Medicine, University of Southampton, UK</nlm:aff></affiliation></author><author><name sortKey="Skyler, Jay S" sort="Skyler, Jay S" uniqKey="Skyler J" first="Jay S" last="Skyler">Jay S. Skyler</name><affiliation><nlm:aff id="aff18">Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA</nlm:aff></affiliation></author><author><name sortKey="Devries, J Hans" sort="Devries, J Hans" uniqKey="Devries J" first="J Hans" last="Devries">J Hans Devries</name><affiliation><nlm:aff id="aff19">Department of Endocrinology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands</nlm:aff></affiliation><affiliation><nlm:aff id="aff20">Profil Institute for Metabolic Research, Neuss, Germany</nlm:aff></affiliation></author><author><name sortKey="Renard, Eric" sort="Renard, Eric" uniqKey="Renard E" first="Eric" last="Renard">Eric Renard</name><affiliation><nlm:aff id="aff21">Montpellier University Hospital and Institute of Functional Genomics, Centre national de la recherche scientifique, INSERM, University of Montpellier, Montpellier, France</nlm:aff></affiliation></author><author><name sortKey="Eckel, Robert H" sort="Eckel, Robert H" uniqKey="Eckel R" first="Robert H" last="Eckel">Robert H. Eckel</name><affiliation><nlm:aff id="aff22">Division of Endocrinology, Metabolism, and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA</nlm:aff></affiliation></author><author><name sortKey="Zimmet, Paul" sort="Zimmet, Paul" uniqKey="Zimmet P" first="Paul" last="Zimmet">Paul Zimmet</name><affiliation><nlm:aff id="aff23">Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia</nlm:aff></affiliation></author><author><name sortKey="Alberti, Kurt George" sort="Alberti, Kurt George" uniqKey="Alberti K" first="Kurt George" last="Alberti">Kurt George Alberti</name><affiliation><nlm:aff id="aff24">Division of Diabetes, Endocrinology and Metabolism, Imperial College, London, UK</nlm:aff></affiliation></author><author><name sortKey="Vidal, Josep" sort="Vidal, Josep" uniqKey="Vidal J" first="Josep" last="Vidal">Josep Vidal</name><affiliation><nlm:aff id="aff25">Centro de Investigación Biomédica en Red en Diabetes y Enfermedades Metabólicas Asociadas, Barcelona, Spain</nlm:aff></affiliation></author><author><name sortKey="Geloneze, Bruno" sort="Geloneze, Bruno" uniqKey="Geloneze B" first="Bruno" last="Geloneze">Bruno Geloneze</name><affiliation><nlm:aff id="aff26">Obesity and Comorbities Research Center, Laboratory of Investigation in Metabolism and Diabetes/Gastrocentro, Universidade de Campinas, Campinas, São Paulo, Brazil</nlm:aff></affiliation></author><author><name sortKey="Chan, Juliana C" sort="Chan, Juliana C" uniqKey="Chan J" first="Juliana C" last="Chan">Juliana C. Chan</name><affiliation><nlm:aff id="aff27">Department of Medicine and Therapeutics, Hong Kong Institute of Diabetes and Obesity and Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China</nlm:aff></affiliation></author><author><name sortKey="Ji, Linong" sort="Ji, Linong" uniqKey="Ji L" first="Linong" last="Ji">Linong Ji</name><affiliation><nlm:aff id="aff28">Department of Endocrinology and Metabolism, Peking University People's Hospital, Peking University Diabetes Center, Beijing, China</nlm:aff></affiliation></author><author><name sortKey="Ludwig, Barbara" sort="Ludwig, Barbara" uniqKey="Ludwig B" first="Barbara" last="Ludwig">Barbara Ludwig</name><affiliation><nlm:aff id="aff1">Department of Medicine III, University Hospital Carl Gustav Carus, Dresden, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Paul Langerhans Institute Dresden of the Helmholtz Center Munich, University Hospital Carl Gustav Carus, Dresden, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff4">Department of Endocrinology and Diabetology, University Hospital Zurich, Zurich, Switzerland</nlm:aff></affiliation><affiliation><nlm:aff id="aff5">Faculty of Medicine, Technische Universität Dresden, Dresden, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff6">Deutsche Forschungsgemeinschaft-Center for Regenerative Therapies Dresden, Technische Universität Dresden, Dresden, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff7">German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">32334646</idno><idno type="pmc">7180013</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7180013</idno><idno type="RBID">PMC:7180013</idno><idno type="doi">10.1016/S2213-8587(20)30152-2</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000957</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000957</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Practical recommendations for the management of diabetes in patients with COVID-19</title><author><name sortKey="Bornstein, Stefan R" sort="Bornstein, Stefan R" uniqKey="Bornstein S" first="Stefan R" last="Bornstein">Stefan R. Bornstein</name><affiliation><nlm:aff id="aff1">Department of Medicine III, University Hospital Carl Gustav Carus, Dresden, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Paul Langerhans Institute Dresden of the Helmholtz Center Munich, University Hospital Carl Gustav Carus, Dresden, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff3">Department of Diabetes, School of Life Course Science and Medicine, King's College London, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="aff4">Department of Endocrinology and Diabetology, University Hospital Zurich, Zurich, Switzerland</nlm:aff></affiliation><affiliation><nlm:aff id="aff5">Faculty of Medicine, Technische Universität Dresden, Dresden, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff7">German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany</nlm:aff></affiliation></author><author><name sortKey="Rubino, Francesco" sort="Rubino, Francesco" uniqKey="Rubino F" first="Francesco" last="Rubino">Francesco Rubino</name><affiliation><nlm:aff id="aff3">Department of Diabetes, School of Life Course Science and Medicine, King's College London, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="aff8">Bariatric and Metabolic Surgery, King's College Hospital, London, UK</nlm:aff></affiliation></author><author><name sortKey="Khunti, Kamlesh" sort="Khunti, Kamlesh" uniqKey="Khunti K" first="Kamlesh" last="Khunti">Kamlesh Khunti</name><affiliation><nlm:aff id="aff9">Diabetes Research Centre, University of Leicester, Leicester, UK</nlm:aff></affiliation></author><author><name sortKey="Mingrone, Geltrude" sort="Mingrone, Geltrude" uniqKey="Mingrone G" first="Geltrude" last="Mingrone">Geltrude Mingrone</name><affiliation><nlm:aff id="aff3">Department of Diabetes, School of Life Course Science and Medicine, King's College London, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="aff10">Fondazione Policlinico Universitario Agostino Gemelli Istituto Di Ricovero e Cura a Carattere Scientifico, Rome, Italy</nlm:aff></affiliation><affiliation><nlm:aff id="aff11">Department of Internal Medicine, Università Cattolica del Sacro Cuore, Rome, Italy</nlm:aff></affiliation></author><author><name sortKey="Hopkins, David" sort="Hopkins, David" uniqKey="Hopkins D" first="David" last="Hopkins">David Hopkins</name><affiliation><nlm:aff id="aff3">Department of Diabetes, School of Life Course Science and Medicine, King's College London, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="aff12">Institute of Diabetes Endocrinology and Obesity, King's Health Partners, London, UK</nlm:aff></affiliation></author><author><name sortKey="Birkenfeld, Andreas L" sort="Birkenfeld, Andreas L" uniqKey="Birkenfeld A" first="Andreas L" last="Birkenfeld">Andreas L. Birkenfeld</name><affiliation><nlm:aff id="aff3">Department of Diabetes, School of Life Course Science and Medicine, King's College London, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="aff7">German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff13">Department of Diabetology, Endocrinology and Nephrology, University Hospital Tübingen, Tübingen, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff14">Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany</nlm:aff></affiliation></author><author><name sortKey="Boehm, Bernhard" sort="Boehm, Bernhard" uniqKey="Boehm B" first="Bernhard" last="Boehm">Bernhard Boehm</name><affiliation><nlm:aff id="aff15">Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore</nlm:aff></affiliation><affiliation><nlm:aff id="aff16">Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore</nlm:aff></affiliation></author><author><name sortKey="Amiel, Stephanie" sort="Amiel, Stephanie" uniqKey="Amiel S" first="Stephanie" last="Amiel">Stephanie Amiel</name><affiliation><nlm:aff id="aff3">Department of Diabetes, School of Life Course Science and Medicine, King's College London, London, UK</nlm:aff></affiliation></author><author><name sortKey="Holt, Richard Ig" sort="Holt, Richard Ig" uniqKey="Holt R" first="Richard Ig" last="Holt">Richard Ig Holt</name><affiliation><nlm:aff id="aff17">Human Development and Health, Faculty of Medicine, University of Southampton, UK</nlm:aff></affiliation></author><author><name sortKey="Skyler, Jay S" sort="Skyler, Jay S" uniqKey="Skyler J" first="Jay S" last="Skyler">Jay S. Skyler</name><affiliation><nlm:aff id="aff18">Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA</nlm:aff></affiliation></author><author><name sortKey="Devries, J Hans" sort="Devries, J Hans" uniqKey="Devries J" first="J Hans" last="Devries">J Hans Devries</name><affiliation><nlm:aff id="aff19">Department of Endocrinology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands</nlm:aff></affiliation><affiliation><nlm:aff id="aff20">Profil Institute for Metabolic Research, Neuss, Germany</nlm:aff></affiliation></author><author><name sortKey="Renard, Eric" sort="Renard, Eric" uniqKey="Renard E" first="Eric" last="Renard">Eric Renard</name><affiliation><nlm:aff id="aff21">Montpellier University Hospital and Institute of Functional Genomics, Centre national de la recherche scientifique, INSERM, University of Montpellier, Montpellier, France</nlm:aff></affiliation></author><author><name sortKey="Eckel, Robert H" sort="Eckel, Robert H" uniqKey="Eckel R" first="Robert H" last="Eckel">Robert H. Eckel</name><affiliation><nlm:aff id="aff22">Division of Endocrinology, Metabolism, and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA</nlm:aff></affiliation></author><author><name sortKey="Zimmet, Paul" sort="Zimmet, Paul" uniqKey="Zimmet P" first="Paul" last="Zimmet">Paul Zimmet</name><affiliation><nlm:aff id="aff23">Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia</nlm:aff></affiliation></author><author><name sortKey="Alberti, Kurt George" sort="Alberti, Kurt George" uniqKey="Alberti K" first="Kurt George" last="Alberti">Kurt George Alberti</name><affiliation><nlm:aff id="aff24">Division of Diabetes, Endocrinology and Metabolism, Imperial College, London, UK</nlm:aff></affiliation></author><author><name sortKey="Vidal, Josep" sort="Vidal, Josep" uniqKey="Vidal J" first="Josep" last="Vidal">Josep Vidal</name><affiliation><nlm:aff id="aff25">Centro de Investigación Biomédica en Red en Diabetes y Enfermedades Metabólicas Asociadas, Barcelona, Spain</nlm:aff></affiliation></author><author><name sortKey="Geloneze, Bruno" sort="Geloneze, Bruno" uniqKey="Geloneze B" first="Bruno" last="Geloneze">Bruno Geloneze</name><affiliation><nlm:aff id="aff26">Obesity and Comorbities Research Center, Laboratory of Investigation in Metabolism and Diabetes/Gastrocentro, Universidade de Campinas, Campinas, São Paulo, Brazil</nlm:aff></affiliation></author><author><name sortKey="Chan, Juliana C" sort="Chan, Juliana C" uniqKey="Chan J" first="Juliana C" last="Chan">Juliana C. Chan</name><affiliation><nlm:aff id="aff27">Department of Medicine and Therapeutics, Hong Kong Institute of Diabetes and Obesity and Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China</nlm:aff></affiliation></author><author><name sortKey="Ji, Linong" sort="Ji, Linong" uniqKey="Ji L" first="Linong" last="Ji">Linong Ji</name><affiliation><nlm:aff id="aff28">Department of Endocrinology and Metabolism, Peking University People's Hospital, Peking University Diabetes Center, Beijing, China</nlm:aff></affiliation></author><author><name sortKey="Ludwig, Barbara" sort="Ludwig, Barbara" uniqKey="Ludwig B" first="Barbara" last="Ludwig">Barbara Ludwig</name><affiliation><nlm:aff id="aff1">Department of Medicine III, University Hospital Carl Gustav Carus, Dresden, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Paul Langerhans Institute Dresden of the Helmholtz Center Munich, University Hospital Carl Gustav Carus, Dresden, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff4">Department of Endocrinology and Diabetology, University Hospital Zurich, Zurich, Switzerland</nlm:aff></affiliation><affiliation><nlm:aff id="aff5">Faculty of Medicine, Technische Universität Dresden, Dresden, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff6">Deutsche Forschungsgemeinschaft-Center for Regenerative Therapies Dresden, Technische Universität Dresden, Dresden, Germany</nlm:aff></affiliation><affiliation><nlm:aff id="aff7">German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany</nlm:aff></affiliation></author></analytic><series><title level="j">The Lancet. Diabetes & Endocrinology</title><idno type="ISSN">2213-8587</idno><idno type="eISSN">2213-8595</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>Summary</title><p>Diabetes is one of the most important comorbidities linked to the severity of all three known human pathogenic coronavirus infections, including severe acute respiratory syndrome coronavirus 2. Patients with diabetes have an increased risk of severe complications including Adult Respiratory Distress Syndrome and multi-organ failure. Depending on the global region, 20–50% of patients in the coronavirus disease 2019 (COVID-19) pandemic had diabetes. Given the importance of the link between COVID-19 and diabetes, we have formed an international panel of experts in the field of diabetes and endocrinology to provide some guidance and practical recommendations for the management of diabetes during the pandemic. We aim to briefly provide insight into potential mechanistic links between the novel coronavirus infection and diabetes, present practical management recommendations, and elaborate on the differential needs of several patient groups.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Chen, Y" uniqKey="Chen Y">Y Chen</name></author><author><name sortKey="Gong, X" uniqKey="Gong X">X Gong</name></author><author><name sortKey="Wang, L" uniqKey="Wang L">L Wang</name></author><author><name sortKey="Guo, J" uniqKey="Guo J">J Guo</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Xue, T" uniqKey="Xue T">T Xue</name></author><author><name sortKey="Li, Q" uniqKey="Li Q">Q Li</name></author><author><name sortKey="Zhang, Q" uniqKey="Zhang Q">Q Zhang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hespanhol, Vp" uniqKey="Hespanhol V">VP Hespanhol</name></author><author><name 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Lancet Diabetes Endocrinol</journal-id><journal-id journal-id-type="iso-abbrev">Lancet Diabetes Endocrinol</journal-id><journal-title-group><journal-title>The Lancet. Diabetes & Endocrinology</journal-title></journal-title-group><issn pub-type="ppub">2213-8587</issn><issn pub-type="epub">2213-8595</issn><publisher><publisher-name>Elsevier Ltd.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">32334646</article-id><article-id pub-id-type="pmc">7180013</article-id><article-id pub-id-type="publisher-id">S2213-8587(20)30152-2</article-id><article-id pub-id-type="doi">10.1016/S2213-8587(20)30152-2</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Practical recommendations for the management of diabetes in patients with COVID-19</article-title></title-group><contrib-group><contrib contrib-type="author" id="au10"><name><surname>Bornstein</surname><given-names>Stefan R</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><email>Stefan.Bornstein@uniklinikum-dresden.de</email><xref rid="aff1" ref-type="aff">a</xref><xref rid="aff2" ref-type="aff">b</xref><xref rid="aff3" ref-type="aff">c</xref><xref rid="aff4" ref-type="aff">d</xref><xref rid="aff5" ref-type="aff">e</xref><xref rid="aff7" ref-type="aff">g</xref><xref rid="cor1" ref-type="corresp">*</xref></contrib><contrib contrib-type="author" id="au20"><name><surname>Rubino</surname><given-names>Francesco</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff3" ref-type="aff">c</xref><xref rid="aff8" ref-type="aff">h</xref></contrib><contrib contrib-type="author" id="au30"><name><surname>Khunti</surname><given-names>Kamlesh</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff9" ref-type="aff">i</xref></contrib><contrib contrib-type="author" id="au40"><name><surname>Mingrone</surname><given-names>Geltrude</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff3" ref-type="aff">c</xref><xref rid="aff10" ref-type="aff">j</xref><xref rid="aff11" ref-type="aff">k</xref></contrib><contrib contrib-type="author" id="au50"><name><surname>Hopkins</surname><given-names>David</given-names></name><degrees>MD</degrees><xref rid="aff3" ref-type="aff">c</xref><xref rid="aff12" ref-type="aff">l</xref></contrib><contrib contrib-type="author" id="au60"><name><surname>Birkenfeld</surname><given-names>Andreas L</given-names></name><degrees>Prof</degrees><xref rid="aff3" ref-type="aff">c</xref><xref rid="aff7" ref-type="aff">g</xref><xref rid="aff13" ref-type="aff">m</xref><xref rid="aff14" ref-type="aff">n</xref></contrib><contrib contrib-type="author" id="au70"><name><surname>Boehm</surname><given-names>Bernhard</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff15" ref-type="aff">o</xref><xref rid="aff16" ref-type="aff">p</xref></contrib><contrib contrib-type="author" id="au80"><name><surname>Amiel</surname><given-names>Stephanie</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff3" ref-type="aff">c</xref></contrib><contrib contrib-type="author" id="au90"><name><surname>Holt</surname><given-names>Richard IG</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff17" ref-type="aff">q</xref></contrib><contrib contrib-type="author" id="au100"><name><surname>Skyler</surname><given-names>Jay S</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff18" ref-type="aff">r</xref></contrib><contrib contrib-type="author" id="au110"><name><surname>DeVries</surname><given-names>J Hans</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff19" ref-type="aff">s</xref><xref rid="aff20" ref-type="aff">t</xref></contrib><contrib contrib-type="author" id="au120"><name><surname>Renard</surname><given-names>Eric</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff21" ref-type="aff">u</xref></contrib><contrib contrib-type="author" id="au130"><name><surname>Eckel</surname><given-names>Robert H</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff22" ref-type="aff">v</xref></contrib><contrib contrib-type="author" id="au140"><name><surname>Zimmet</surname><given-names>Paul</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff23" ref-type="aff">w</xref></contrib><contrib contrib-type="author" id="au150"><name><surname>Alberti</surname><given-names>Kurt George</given-names></name><degrees>Prof</degrees><degrees>FRCP</degrees><xref rid="aff24" ref-type="aff">x</xref></contrib><contrib contrib-type="author" id="au160"><name><surname>Vidal</surname><given-names>Josep</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff25" ref-type="aff">y</xref></contrib><contrib contrib-type="author" id="au170"><name><surname>Geloneze</surname><given-names>Bruno</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff26" ref-type="aff">z</xref></contrib><contrib contrib-type="author" id="au180"><name><surname>Chan</surname><given-names>Juliana C</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff27" ref-type="aff">aa</xref></contrib><contrib contrib-type="author" id="au190"><name><surname>Ji</surname><given-names>Linong</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff28" ref-type="aff">ab</xref></contrib><contrib contrib-type="author" id="au200"><name><surname>Ludwig</surname><given-names>Barbara</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff1" ref-type="aff">a</xref><xref rid="aff2" ref-type="aff">b</xref><xref rid="aff4" ref-type="aff">d</xref><xref rid="aff5" ref-type="aff">e</xref><xref rid="aff6" ref-type="aff">f</xref><xref rid="aff7" ref-type="aff">g</xref></contrib><aff id="aff1"><label>a</label>Department of Medicine III, University Hospital Carl Gustav Carus, Dresden, Germany</aff><aff id="aff2"><label>b</label>Paul Langerhans Institute Dresden of the Helmholtz Center Munich, University Hospital Carl Gustav Carus, Dresden, Germany</aff><aff id="aff3"><label>c</label>Department of Diabetes, School of Life Course Science and Medicine, King's College London, London, UK</aff><aff id="aff4"><label>d</label>Department of Endocrinology and Diabetology, University Hospital Zurich, Zurich, Switzerland</aff><aff id="aff5"><label>e</label>Faculty of Medicine, Technische Universität Dresden, Dresden, Germany</aff><aff id="aff6"><label>f</label>Deutsche Forschungsgemeinschaft-Center for Regenerative Therapies Dresden, Technische Universität Dresden, Dresden, Germany</aff><aff id="aff7"><label>g</label>German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany</aff><aff id="aff8"><label>h</label>Bariatric and Metabolic Surgery, King's College Hospital, London, UK</aff><aff id="aff9"><label>i</label>Diabetes Research Centre, University of Leicester, Leicester, UK</aff><aff id="aff10"><label>j</label>Fondazione Policlinico Universitario Agostino Gemelli Istituto Di Ricovero e Cura a Carattere Scientifico, Rome, Italy</aff><aff id="aff11"><label>k</label>Department of Internal Medicine, Università Cattolica del Sacro Cuore, Rome, Italy</aff><aff id="aff12"><label>l</label>Institute of Diabetes Endocrinology and Obesity, King's Health Partners, London, UK</aff><aff id="aff13"><label>m</label>Department of Diabetology, Endocrinology and Nephrology, University Hospital Tübingen, Tübingen, Germany</aff><aff id="aff14"><label>n</label>Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany</aff><aff id="aff15"><label>o</label>Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore</aff><aff id="aff16"><label>p</label>Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore</aff><aff id="aff17"><label>q</label>Human Development and Health, Faculty of Medicine, University of Southampton, UK</aff><aff id="aff18"><label>r</label>Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA</aff><aff id="aff19"><label>s</label>Department of Endocrinology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands</aff><aff id="aff20"><label>t</label>Profil Institute for Metabolic Research, Neuss, Germany</aff><aff id="aff21"><label>u</label>Montpellier University Hospital and Institute of Functional Genomics, Centre national de la recherche scientifique, INSERM, University of Montpellier, Montpellier, France</aff><aff id="aff22"><label>v</label>Division of Endocrinology, Metabolism, and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA</aff><aff id="aff23"><label>w</label>Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia</aff><aff id="aff24"><label>x</label>Division of Diabetes, Endocrinology and Metabolism, Imperial College, London, UK</aff><aff id="aff25"><label>y</label>Centro de Investigación Biomédica en Red en Diabetes y Enfermedades Metabólicas Asociadas, Barcelona, Spain</aff><aff id="aff26"><label>z</label>Obesity and Comorbities Research Center, Laboratory of Investigation in Metabolism and Diabetes/Gastrocentro, Universidade de Campinas, Campinas, São Paulo, Brazil</aff><aff id="aff27"><label>aa</label>Department of Medicine and Therapeutics, Hong Kong Institute of Diabetes and Obesity and Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China</aff><aff id="aff28"><label>ab</label>Department of Endocrinology and Metabolism, Peking University People's Hospital, Peking University Diabetes Center, Beijing, China</aff></contrib-group><author-notes><corresp id="cor1"><label>*</label>Correspondence to: Prof S R Bornstein, Department of Medicine III, University Hospital Carl Gustav Carus, 01307 Dresden, Germany <email>Stefan.Bornstein@uniklinikum-dresden.de</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>23</day><month>4</month><year>2020</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="epub"><day>23</day><month>4</month><year>2020</year></pub-date><permissions><copyright-statement>© 2020 Elsevier Ltd. All rights reserved.</copyright-statement><copyright-year>2020</copyright-year><copyright-holder>Elsevier Ltd</copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="ceab10"><title>Summary</title><p>Diabetes is one of the most important comorbidities linked to the severity of all three known human pathogenic coronavirus infections, including severe acute respiratory syndrome coronavirus 2. Patients with diabetes have an increased risk of severe complications including Adult Respiratory Distress Syndrome and multi-organ failure. Depending on the global region, 20–50% of patients in the coronavirus disease 2019 (COVID-19) pandemic had diabetes. Given the importance of the link between COVID-19 and diabetes, we have formed an international panel of experts in the field of diabetes and endocrinology to provide some guidance and practical recommendations for the management of diabetes during the pandemic. We aim to briefly provide insight into potential mechanistic links between the novel coronavirus infection and diabetes, present practical management recommendations, and elaborate on the differential needs of several patient groups.</p></abstract></article-meta></front><body><sec id="cesec10"><title>Introduction</title><p id="para260">From January, 2020, we have been facing an unprecedented outbreak of coronavirus disease 2019 (COVID-19) caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has now become a global catastrophe. Data from the early months of 2020 suggest that most people with COVID-19 have comorbidities, the most prevalent of which are diabetes, cardiovascular disease, and hypertension.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> A significant association with worse outcomes is seen in people with these comorbidities.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> Studies have also shown that COVID-19 is associated with hyperglycaemia particularly in the elderly with type 2 diabetes.<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref> In view of many uncertainties with COVID-19, a faculty of representatives from primary and specialist care have developed a consensus document on the management of diabetes for people at risk of or with confirmed COVID-19 for use in both primary and specialist care. The brief practical recommendations authored by this group were convened virtually. The recommendations are based on queries that have been emphasised to be important by clinicians, questions that have been raised by colleagues and social media, and recommendations guided by using focused-literature review. Clinical decision making in the management of diabetes is already complex and in normal circumstances we recommend clinicians follow guidelines for management of people with diabetes. However, the recommendations authored by our group add to the existing guidelines by considering specific points for the management of patients with diabetes and COVID-19 disease or at risk for metabolic disease.</p></sec><sec id="cesec20"><title>The potential links between diabetes and COVID-19 infection</title><p id="para270">Diabetes is a primary risk factor for the development of severe pneumonia and a septic course due to virus infections and occurs in around 20% of patients.<xref rid="bib3" ref-type="bibr">3</xref>, <xref rid="bib4" ref-type="bibr">4</xref> Diabetes was identified as a major contributor to disease severity and mortality in Middle East Respiratory Syndrome (MERS-CoV).<xref rid="bib5" ref-type="bibr"><sup>5</sup></xref> Evidence from epidemiological observations in regions heavily affected by SARS-CoV-2 and reports from the <ext-link ext-link-type="uri" xlink:href="https://www.cdc.gov/mmwr/Novel_Coronavirus_Reports.html" id="interrefs10">Centers for Disease Control</ext-link> and Prevention (CDC) and <ext-link ext-link-type="uri" xlink:href="https://www.iss.it/en/coronavirus" id="interrefs20">other national health centres and hospitals</ext-link> showed that the risk of a fatal outcome from COVID-19 is up to 50% higher in patients with diabetes than in those who do not have diabetes.<xref rid="bib6" ref-type="bibr"><sup>6</sup></xref> There are several hypotheses to explain the increased incidence and severity of COVID-19 infection in people with diabetes. In general, people with all forms of diabetes are at increased risk of infection because of defects in innate immunity affecting phagocytosis, neutrophil chemotaxis, and cell-mediated immunity; however, the high frequency of diabetes in serious cases of COVID-19 could potentially reflect the higher prevalence of type 2 diabetes in older people. Furthermore, diabetes in older age is associated with cardiovascular disease, which in itself could help to explain the association with fatal outcomes of COVID-19.</p><p id="para280">There are at least two specific mechanisms that might play a role in COVID-19 infection. First, to gain entry to its target cells, the SARS-CoV-2 virus hijacks an endocrine pathway that plays a crucial role in blood pressure regulation, metabolism, and inflammation.<xref rid="bib7" ref-type="bibr"><sup>7</sup></xref> Angiotensin-converting-enzyme 2 (ACE2) has been identified as the receptor for the coronavirus spike protein. ACE2 has protective effects primarily regarding inflammation. COVID-19 infection reduces ACE2 expression inducing cellular damage, hyperinflammation, and respiratory failure.<xref rid="bib7" ref-type="bibr"><sup>7</sup></xref> Acute hyperglycaemia has been shown to upregulate ACE2 expression on cells which might facilitate viral cell entry. However, chronic hyperglycaemia is known to downregulate ACE2 expression making the cells vulnerable to the inflammatory and damaging effect of the virus. Furthermore, the expression of ACE2 on pancreatic β cells can lead to a direct effect on β cell function.<xref rid="bib8" ref-type="bibr">8</xref>, <xref rid="bib9" ref-type="bibr">9</xref>, <xref rid="bib10" ref-type="bibr">10</xref> Although these findings have not been verified in humans, they suggest that diabetes might not only be a risk factor for a severe form of COVID-19 disease but also that infection could induce new onset diabetes.<xref rid="bib8" ref-type="bibr">8</xref>, <xref rid="bib9" ref-type="bibr">9</xref>, <xref rid="bib10" ref-type="bibr">10</xref> Potential β cell damage caused by the virus leading to insulin deficiency is supported by the observation of Italian colleagues and co-authors of these recommendations who have reported frequent cases of severe diabetic ketoacidosis (DKA) at the time of hospital admission. Another important observation by the co-authors from various centres in different countries affected by COVID-19 is the tremendous insulin requirement in patients with a severe course of the infection. To what extent COVID-19 plays a direct role in this high insulin resistance is unclear. According to the personal experiences of co-authors of this Personal View, the extent of insulin resistance in patients with diabetes seems disproportionate compared with critical illness caused by other conditions.</p><p id="para290">A second potential mechanism that might explain the link between COVID-19 and diabetes involves the dipeptidyl peptidase-4 (DPP-4) enzyme, which is commonly targeted pharmacologically in people with type 2 diabetes. In cell studies, DPP-4 was identified as a functional receptor for human coronavirus-Erasmus Medical Center (hCoV-EMC), the virus responsible for MERS.<xref rid="bib11" ref-type="bibr"><sup>11</sup></xref> Antibodies directed against DPP-4 inhibited hCoV-EMC infection of primary cells. DPP-4 enzyme is an ubiquitously expressed type II transmembrane glycoprotein. It plays a major role in glucose and insulin metabolism but also increases inflammation in type 2 diabetes.<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref> Whether these mechanisms also apply to COVID-19 and whether diabetes treatment with DPP-4 inhibitors in clinical practice influences the course of the infection is currently unknown, but, if these mechanisms translate to SARS-CoV-2, the use of these agents could reduce DPP-4 concentrations and could provide therapeutic opportunities for treatment of COVID-19.<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref></p></sec><sec id="cesec30"><title>Implications on diabetes management</title><p id="para300">The clinical relevance of the aforementioned mechanisms is currently uncertain, but health-care practitioners should be aware of their implications for patients with diabetes. We have compiled a simple flowchart for the metabolic screening and management of patients with COVID-19 and diabetes or at risk for metabolic disease. This includes recommendations regarding both the need for primary prevention of diabetes as well as the avoidance of severe sequelae of diabetes triggered by unidentified or poorly managed diabetes (<xref rid="fig1" ref-type="fig">figure</xref>). Furthermore, special considerations on anti-diabetes drugs commonly used in patients with type 2 diabetes in view of COVID-19 are presented in the <xref rid="box1" ref-type="boxed-text">panel</xref>.<fig id="fig1"><label>Figure</label><caption><p>Flowchart for metabolic screening and type 1 and 2 diabetes management of patients with COVID-19</p><p>Older patients refers to those aged 70 and above. ARDS=Acute Respiratory Distress Syndrom. CGM=Continous Glucose Measurement. FGM=Flash Glucose Measurement. HbA<sub>1c</sub>=haemoglobin A<sub>1c</sub>. TIR=time in range. *Target concentrations for lower plasma glucose can be adjusted to 5 mmol/l (90 mg/dl) in frail patients. †HbA<sub>1c</sub> testing might not be possible at the time, but previous measurements if available allow for differentiation of chronic and acute decompensation.</p></caption><graphic xlink:href="gr1_lrg"></graphic></fig><boxed-text id="box1"><label>Panel</label><caption><title>Consideration of potential metabolically interfering effects of drugs in suspected or COVID-19 positive patients with type 2 diabetes</title></caption><p id="para10"><bold>Metformin</bold></p><p id="para20"><list list-type="simple" id="celist10"><list-item id="celistitem10"><label>•</label><p id="para30">Dehydration and lactic acidosis will probably occur if patients are dehydrated, so patients should stop taking the drug and follow sick day rules</p></list-item><list-item id="celistitem20"><label>•</label><p id="para40">During illness, renal function should be carefully monitored because of the high risk of chronic kidney disease or acute kidney injury</p></list-item></list></p><p id="para50"><bold>Sodium-glucose-co-transporter 2 inhibitors</bold></p><p id="para60"><list list-type="simple" id="celist20"><list-item id="celistitem30"><label>•</label><p id="para70">These include canagliflozin, dapagliflozin, and empagliflozin</p></list-item><list-item id="celistitem40"><label>•</label><p id="para80">Risk of dehydration and diabetic ketoacidosis during illness, so patients should stop taking the drugs and follow sick day rules</p></list-item><list-item id="celistitem50"><label>•</label><p id="para90">Patients should avoid initiating therapy during respiratory illness</p></list-item><list-item id="celistitem60"><label>•</label><p id="para100">Renal function should be carefully monitored for acute kidney injury</p></list-item></list></p><p id="para110"><bold>Glucagon-like peptide-1 receptor agonists</bold></p><p id="para120"><list list-type="simple" id="celist30"><list-item id="celistitem70"><label>•</label><p id="para130">These include albiglutide, dulaglutide, exenatide-extended release, liraglutide, lixisenatide, and semaglutide</p></list-item><list-item id="celistitem80"><label>•</label><p id="para140">Dehydration is likely to lead to a serious illness so patients should be closely monitored</p></list-item><list-item id="celistitem90"><label>•</label><p id="para150">Adequate fluid intake and regular meals should be encouraged</p></list-item></list></p><p id="para160"><bold>Dipeptidyl peptidase-4 inhibitors</bold></p><p id="para170"><list list-type="simple" id="celist40"><list-item id="celistitem100"><label>•</label><p id="para180">These include alogliptin, linagliptin, saxagliptin, and sitagliptin</p></list-item><list-item id="celistitem110"><label>•</label><p id="para190">These drugs are generally well tolerated and can be continued</p></list-item></list></p><p id="para200"><bold>Insulin</bold></p><p id="para210"><list list-type="simple" id="celist50"><list-item id="celistitem120"><label>•</label><p id="para220">Insulin therapy should not be stopped</p></list-item><list-item id="celistitem130"><label>•</label><p id="para230">Regular self-monitoring of blood-glucose every 2–4 hours should be encouraged, or continuous glucose monitoring</p></list-item><list-item id="celistitem140"><label>•</label><p id="para240">Carefully adjust regular therapy if appropriate to reach therapeutic goals according to diabetes type, comorbidities, and health status</p></list-item></list></p><p id="para250">Connected Health models and Telemedicine should be used to continue regular reviews and self-management education programmes virtually and ensure patients are adherent to therapy.</p></boxed-text></p><sec id="cesec40"><title>Metabolic and glycaemic control</title><p id="para310">People with diabetes who have not yet been infected with the SARS-CoV-2 virus should intensify their metabolic control as needed as means of primary prevention of COVID-19 disease. This includes continuation and strict abidance with adequate control of blood pressure and lipids. Wherever possible, remote consultations using Connected Health models should be utilised to reduce exposure. They should also be encouraged to follow general advice from WHO, the CDC, and state and local governments about hand washing and physical distancing.</p><p id="para320">All patients without diabetes and particularly when at high risk for metabolic disease who have contracted the viral infection need to be monitored for new onset diabetes that might be triggered by the virus. All patients with COVID-19 disease and diabetes require continuous and reliable glycaemic control as suggested in the flowchart.</p></sec><sec id="cesec50"><title>Management of hyperglycaemia and associated metabolic conditions</title><p id="para330">Most patients with type 2 diabetes have other components of the metabolic syndrome including hypertension and dyslipidaemia. Therefore, continuation with an appropriate antihypertensive and lipid-lowering regimen in all these patients is of crucial importance.</p><p id="para340">Treatment with ACE inhibitors and angiotensin 2 receptor blockers could increase the expression of ACE2, which could accelerate the entry of the virus into the cells.<xref rid="bib13" ref-type="bibr"><sup>13</sup></xref> However, as SARS-CoV-2 might impair the protective ACE2/Mas receptor pathway and increase deleterious angiotensin-2 activity, the use of ACE inhibitors and angiotensin 2 receptor blockers could protect against severe lung injury following infection. On the basis of currently available evidence, we recommend that patients should continue with their antihypertensive regimens including ACE inhibitors and angiotensin 2 receptors. This view is endorsed by a recent position statement from the European Society of Cardiology and the Heart Failure Society of America, American College of Cardiology, American Heart Association, who strongly recommended continuation of treatment with ACE inhibitors and angiotensin 2 receptor blockers.<xref rid="bib14" ref-type="bibr"><sup>14</sup></xref></p><p id="para350">Statins have been shown to restore the reduction of ACE2 induced by high lipids such as low density lipoprotein or lipoprotein(a).<xref rid="bib15" ref-type="bibr"><sup>15</sup></xref> The pleiotropic anti-inflammatory effects of statins have been attributed to the upregulation of ACE2. However, although we believe that modulation of ACE2 expression is associated with both infection and mortality rates in COVID-19, statins should not be discontinued because of the long-term benefits and the potential for tipping the balance towards a cytokine storm by rebound rises in interleukin(IL)-6 and IL-1ß if they were to be discontinued. Given the close links between diabetes and cardiovascular disease, we recommend control of lipid concentrations in all patients with COVID-19.</p><p id="para360">There are certain subgroups of people with diabetes who might require specific consideration. Elevated hemoglobin A<sub>1c</sub> in people with type 1 diabetes compromises immune function rendering them more susceptible to any infectious disease. These individuals will need more intense monitoring and supportive therapy to reduce the risk of metabolic decompensation including DKA, in particular for those taking sodium glucose co-transporter 2 inhibitors (SGLT2). According to the expertise from the co-authors, an increase in the prevalence of severe DKA in COVID-19 positive patients with established type 1 diabetes has been observed, but this might in part be because of delayed hospital admission. Thus, making patients with type 1 diabetes aware of this complication and re-educating them about typical symptoms, home-measurement of urine or blood ketones, acute behaviour guidelines, and liberal and early inquiry of professional medical advice and sick day rules is crucial. Patients who have undergone transplantation of islets, pancreas or kidney, or those on immunosuppressive therapy will be at particularly increased risk; additionally, the potential effect of coronavirus infection on pancreatic function in this group is unknown and monitoring for a recurrence of insulin requirement in those who are insulin independent after their transplant is important.</p><p id="para370">The increasing number of patients with type 2 diabetes and concomitant fatty liver disease will probably have an increased risk for a more pronounced inflammatory response including the so-called cytokine storm, and these patients should be considered at increased risk of severe COVID-19 disease. Therefore, screening for hyperinflammation using laboratory trends (eg, increasing ferritin, decreasing platelet counts, high-sensitivity C-reactive protein, or erythrocyte sedimentation rate) are of crucial importance and might also help to identify subgroups of patients for whom immunosuppression (steroids, immunoglobulins, selective cytokine blockade) could improve the outcome.</p><p id="para380">The majority of patients with type 2 diabetes are living with conditions of overweight or obesity. Body mass index is an important determinant of lung volume, respiratory mechanics, and oxygenation during mechanical ventilation, especially in the supine position. Therefore, patients with obesity and diabetes could be at specific risk of ventilatory failure and complications during mechanical ventilation. Clinical experience with young patients with obesity and COVID-19 supports this notion. Furthermore, individuals with obesity or with diabetes have an altered innate and adaptive immune response, characterised by a state of chronic and low-grade inflammation with higher concentrations of the pro-inflammatory leptin and lower anti-inflammatory adiponectin.<xref rid="bib16" ref-type="bibr"><sup>16</sup></xref> Additionally, obesity is often associated with physical inactivity leading to aggravated insulin resistance. This condition per se impairs immune response against microbial agents including macrophage activation and inhibition of pro-inflammatory cytokines and leads to a dysregulation of the immune response contributing to complications associated with obesity.<xref rid="bib17" ref-type="bibr"><sup>17</sup></xref></p><p id="para390">Furthermore, SARS-CoV-2 can induce long-term metabolic alterations in patients who have been infected with the virus, as has been reported previously with the SARS virus.<xref rid="bib18" ref-type="bibr"><sup>18</sup></xref> Therefore, a careful cardiometabolic monitoring of patients who have survived severe COVID-19 disease might be necessary.</p><p id="para400">Importantly, we should also bring attention to the subgroup of people with diabetes who work as health-care professionals. Given that COVID-19 might be more prevalent among the sick than is currently being diagnosed, health-care professionals with diabetes should be deployed away from front line clinical duties where possible. For cases in which this is not possible or desirable, high-grade protection or increased protection should be used.</p></sec><sec id="cesec60"><title>Surgical treatment of type 2 diabetes—metabolic surgery</title><p id="para410">Provision of elective surgical procedures—including metabolic surgery—is being postponed in many hospitals around the world to increase capacity for in-patient beds and acute care. However, postponing elective metabolic surgery during the outbreak of COVID-19 is advisable regardless of issues of hospital capacity. Patients with type 2 diabetes and obesity are at increased risk of complications of COVID-19,<xref rid="bib17" ref-type="bibr"><sup>17</sup></xref> compounding the potential negative influence of surgical stress in the recovery period. Furthermore, although specific data are not available, there are plausible concerns that pneumoperitoneum and the use of haemostatic instruments during laparoscopy (by far the most common approach used in metabolic surgery because of its ability to reduce morbidity and mortality) might lead to viral aerosolisation, thus increasing the risk of transmission of the virus to both patients and staff.</p><p id="para420">Whether patients with type 2 diabetes who have had metabolic surgery will be protected from adverse outcomes of COVID-19 relative to their peers who have not undergone surgical treatment simply because of better glycaemic control remains unclear.<xref rid="bib19" ref-type="bibr"><sup>19</sup></xref> However, metabolic surgery could induce nutritional deficiencies, including reduced absorption of vitamins and micronutrients, which play important roles in the regulation of the immune and stress response.<xref rid="bib20" ref-type="bibr"><sup>20</sup></xref> Although there are no data yet to suggest that patients who had metabolic surgery are at greater risk of infection or complications from COVID-19, these patients should receive particular attention and close monitoring.</p></sec><sec id="cesec70"><title>Special considerations on use of diabetes drugs</title><p id="para430">Although optimising glycaemic control to reduce the risk of severe COVID-19 disease is important, specific considerations around treatment modality should be made (<xref rid="box1" ref-type="boxed-text">panel</xref>). Lactic acidosis associated with metformin, or euglycaemic or moderate hyperglycaemic diabetic ketoacidosis associated with SGLT-2 inhibitors are rare events; however, we recommend these drugs should be discontinued for patients with severe symptoms of COVID-19 to reduce the risk of acute metabolic decompensation.<xref rid="bib21" ref-type="bibr"><sup>21</sup></xref> Importantly, discontinuing these drugs is not recommended prophylactically for out-patients with diabetes without any symptoms of infection or in the absence of evidence for a serious course of COVID-19. Furthermore, at present, no convincing evidence exists to suggest that DPP-4 inhibitors should be discontinued. Further analyses on affected patients with various diabetes treatments and COVID-19 could allow elucidation of the effects of DPP-4 inhibitors.<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref> Importantly, if drugs are discontinued, the alternative treatment of choice—in cases for which this option is feasible—is insulin.<xref rid="bib21" ref-type="bibr"><sup>21</sup></xref></p><p id="para440">Given the multiple stresses associated with COVID-19 including but not limited to respiratory failure, the defects in insulin secretion and the frequent occurrence of diarrhoea and sepsis, most patients will require insulin and especially since many cases are reported with very high insulin consumption, this will need to be managed by intravenous infusion.<xref rid="bib22" ref-type="bibr"><sup>22</sup></xref> Considerable care is required in fluid balance as there is a risk that excess fluid can exacerbate pulmonary oedema in the severely inflamed lung. Furthermore, potassium balance needs to be considered carefully in the context of insulin treatment as hypokalaemia is a common feature in COVID-19 (possibly associated with hyperaldosteronism induced by high concentrations of angiotensin 2) and could be exacerbated following initiation of insulin.<xref rid="bib22" ref-type="bibr"><sup>22</sup></xref></p><p id="para450">We do realise that all our recommendations and reflections are based on our expert opinion, awaiting the outcome of randomised clinical trials. Executing clinical trials under challenging circumstances has been proven feasible during the COVID-19 pandemic, and trial networks to provide evidence-based therapies are arising.<xref rid="bib23" ref-type="bibr"><sup>23</sup></xref> Investigating subgroups with diabetes and how these relate to COVID-19 outcomes will be important, in particular investigating if some of the various management approaches would be particularly effective in managing diabetes in a COVID-19 context.<xref rid="bib24" ref-type="bibr"><sup>24</sup></xref></p></sec></sec><sec id="cesec80"><title>Search strategy and selection criteria</title><p id="para460"><boxed-text id="cetextbox10"><p id="para470">We identified the references for this publication through searches of PubMed for articles published between Apr 29, 2009, and Apr 5, 2020, using combinations of the terms “coronavirus”, “COVID-19”, “SARS-CoV-2”, “nCoV”, “diabetes”, “risk factors”, “severe acute respiratory syndrome”, “acute respiratory distress syndrome”, and “co-morbidities”. We reviewed guidelines for the management of COVID-19 published by WHO, American Diabetes Assiciation, and the US Centers for Disease Control and Prevention. We added articles through searches of the authors' personal files. We also reviewed relevant references cited in retrieved articles. Articles published in English, Italian, and Chinese were included. 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studies</article-title><source>J Diabetes Res</source><volume>2020</volume><year>2020</year><object-id pub-id-type="publisher-id">5214751</object-id></element-citation></ref></ref-list><ack id="ceack10"><sec><title>Acknowledgments</title><p>KK acknowledges support from NIHR Applied Research Collaboration East Midlands. SRB, FR, GM, DH, ALB, BB, SA, and BL acknowledge support from the Transcampus Initiative.</p></sec></ack><ack><title>Contributors</title><p>All authors did the literature search and drafted sections of the manuscript. SRB and BL combined and edited the drafts and supervised the manuscript. BL prepared the panel and figure of the manuscript. All authors subsequently revised the final manuscript.</p></ack><ack><title>Declaration of interests</title><p>SA reports that she serves on Advisory Boards for Novo Nordisk, Abbott, and Medtronic. All other authors declare no competing interests.</p></ack></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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