Bangladesh Endocrine Society (BES) Position Statement for Management of Diabetes and Other Endocrine Diseases in Patients with COVID-19

Figures & data

Figure 1 Suggested mechanisms of increased severity of COVID-19 in diabetes.

Table 1 Plasma Glucose Targets

	Strict Control (Mild and Moderate Illness in Young)	Medium Control (Mild and Moderate Illness in Elderly, or Patients on Glucocorticoids and in Resource-Poor Inpatient Care Settings)	Low Control (Severe Illness, Hypoglycemia Intolerable Patients, or Patients Having Organ Dysfunctions or Serious Cardiovascular or Cerebrovascular Diseases)
Fasting (mmol/L)	4.4–6.1 (80–110 mg/dL)	6.1–7.8 (110–140 mg/dL)	7.8–10.0 (140–180 mg/dL)
2 h post-prandial (mmol/L)	6.1–7.8 (110–140 mg/dL)	7.8–10.0 (140–180 mg/dL)	7.8–13.9 (140–250 mg/dL)

Note: Data from Cemiyeti.¹⁸

Table 2 SMBG Frequency

Type of Diabetes	Patient Category	Recommended Frequency of SMBG
Type 2 DM	On Sulphonylureas or Meglitinides	Four times/day and should include preprandial, post-prandial and bedtime levels. In well-controlled diabetes, daily fasting and after the major meal may be justified.
	On other OADs	Fasting and post-prandial capillary blood glucose once or twice a week.
	On Insulin ± OADs	At least 4 times/day and should include preprandial, post-prandial and bedtime levels.
Diabetes in pregnancy	On lifestyle modifications	A day profile once a week FBG and 3 post-prandial values at least once a week or staggered over the week.
	On insulin	At least 4 times/day (FBG and 3 post-prandial values).
Type 1 DM	On multiple dose insulin injection	Pre- and post-meals, at bedtime, at 3am (if nocturnal hypoglycemia).

Note: Data from Banerjee et al,¹⁹ Basu et al,²⁰ and Rao et al.²¹ Abbreviations: OAD, oral antidiabetic drug; FBG, fasting blood glucose.

Table 3 Indications of Hospitalization vs Home Management in Diabetic Patients with COVID-19

Diabetes Mellitus with COVID-19 Disease
Who Can Be Treated at Home^Citation1	Indication for Hospitalization^Citation33,Citation34
Mild COVID-19 cases having uncomplicated upper respiratory tract infection with non-specific symptoms (such as fever, fatigue, cough with or without sputum, sore throat, nasal congestion, anorexia, malaise, or headache).	Blood glucose >15 mmol/l (>270 mg/dL) on repeated measurements. Ketones in urine. Excessive thirst. Vomiting or diarrhea persist for more than 6 hours. Unable to take food and drinks for 6 hours. Weight loss of ≥2.5 kg during the illness. Rapid breathing. Abdominal pain. Reduced level of consciousness (drowsiness). Co-existing serious morbidities. Clinical feature of moderate, severe and critical Covid-19 cases

Table 4 Recommendations for Anti-Diabetic Agents

Therapy	Suggestions for Practice
Metformin	Continue in mild to moderate COVID-19. Stop if severely or critically ill or contraindications like renal failure/hypoxia/acute GI symptoms/dehydration
Sulfonylureas	Continue, adjust dose according to glycemic state, stop if unable to maintain regular oral food intake or at risk of hypoglycemia or if insulin is started or if severely/critically ill
SGLT2 inhibitors	Stop if hospitalized with acute illness/severely or critically ill/acute GI symptoms/dehydration
GLP-1RAs	Continue in mild to moderate COVID-19 but stop if acute GI symptoms/dehydration
DPP4 inhibitors	Continue in mild to moderate COVID-19. Avoid in severe/critical cases
Pioglitazone	Continue in mild to moderate COVID-19. Use cautiously where volume overload. Stop if severely/critically ill with hemodynamic instability, and hepatic and cardiac dysfunction
Insulin	Continue at any stage, adjust dose according to glycemic state, often require high dose

Note: Data from Bornstein et al,² Singh and Khunti,⁴¹ Singh et al,⁴² Ceriello,⁵¹ Royal Australian College of General Practitioners,⁵⁴ and Ceriello et al.⁵⁵

Table 5 Recommendations for Drugs Used for CoMorbid Diseases of Diabetes

Therapy	Considerations for Use During COVID-19	Suggestions for Practice
ACEI/ARBs	Uncertain risk/benefit – ACEi and ARB could increase the expression of ACE2, which could accelerate the entry of the virus into the cells, but on the other hand also increase protective anti-inflammatory effect which could protect against severe lung injury	Continue unless specific contraindications
Statins	Restore the reduction of ACE2 induced by high lipids such as LDL or lipoprotein(a) Have anti-inflammatory effects probably due to the upregulation of ACE2 Possibility of increased risk of myositis with experimental antiviral agents/macrolides	Continue but monitor risk

Note:Data from Ceriello et al⁴⁸ and Royal Australian College of General Practitioners.⁵⁴ 

Table 6 Recommendations for Management of Diabetes According to Severity

Severity of COVID-19	Treatment Regimen
Mild	Continue current treatment of oral antidiabetic agents (OAD) and/or insulin/GLP1-agonists. Monitor BG frequently and adjust regimen accordingly
Moderate	Continue current treatment regimen if appetite is normal, patient can take food regularly and blood glucose is controlled If patient cannot eat regularly or blood glucose is high -If on OAD/Premixed insulin/GLP1-agonists → switch to Basal- bolus/Split-mix SC insulin or IV insulin and adjust dose according to blood glucose profile. TDD premixed insulin is converted to same TDD of Split-mix/Basal-bolus insulin
Severe and Critical	IV insulin should be the 1st line treatment, but SC insulin may be used in severe case, especially if insulin pump is not available
On steroid	Long acting insulin/NPH - 10-20 U once/two divided doses daily and add rapid/short acting insulin subsequently depending on blood glucose.

Note:Data from Alshaikh et al.¹⁰

Table 7 Precautions to Prevent COVID-19 in People with Diabetes

General Precautions for COVID Prevention: Hand hygiene Respiratory hygiene Social and physical distancing Avoid non-essential travels

Specific Precautions for Diabetic Patients During COVID Pandemic: Frequent BG monitoring Good glycemic control Stabilize cardiac & renal status (control BP and lipid, stop smoking) Proper nutrition Regular exercise Vaccinate if not taken previously* (e.g., influenza, pneumococcus)

Note: *Patients with diabetes should be vaccinated against COVID-19 complying with national policies.

Figure 2 Screening for women with risk factors for GDM.

Note:Data from Ceriello et al.⁵⁵

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