A team from the University of Michigan have developed an algorithm to help treat COVID-19 patients with diabetes. The tool could reduce the risk of complications, such as kidney failure and respiratory distress, in these people.
People with diabetes are one of the groups at higher risk of severe illness from COVID-19. Although people with diabetes are not more likely to contract the disease initially, they are more likely to face worse outcomes.
Complications in people with diabetes include elevation of blood glucose levels, diabetic ketoacidosis, and pneumonia. There is also an elevated risk of more severe outcomes. One study in England found that one-third of COVID-19-related deaths in the hospitals were people with diabetes.
Although scientists do not fully understand why people with diabetes are at increased risk from COVID-19, it seems that high blood sugar levels may be the trigger.
A recent study, for example, found that high blood glucose has associations with inflammation, a process responsible for some of the worst outcomes of COVID-19.
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In a new study published in the journal Diabetes, a team from the University of Michigan describes the management of almost 200 COVID-19 hospitalized patients with high blood sugar levels.
From their observations, the team developed an algorithm to help doctors manage the blood sugar levels in people who have COVID-19 and diabetes.
They say the tool could help reduce the risk of severe complications, including kidney failure and severe respiratory distress, in these patients.
Diabetes and inflammation
The researchers based the report on the experience at the University of Michigan hospital. Michigan has a relatively high number of COVID-19 cases and high rates of complications, with over 93,600 confirmed cases and almost 6,400 deaths at the time of writing.
The University of Michigan hospital treated around 500 patients with COVID-19 from the start of the pandemic to the time of the study. Of these, they knew that roughly a third had diabetes.
The researchers also included additional patients with no history of diabetes who developed high blood glucose levels (hyperglycemia) while in the hospital.
Clinical tests in these patients suggest that hyperglycemia is associated with damaging inflammatory processes.
“When the body becomes this inflamed, it triggers an abnormal immune response that instead of just attacking the virus, affects the rest of the body’s healthy cells and tissue, leading to rapid deterioration in health,” explains the senior author of the study Dr. Rodica Pop-Busui.
The authors suggest the presence of diabetes may prompt an inflammatory surge in COVID-19, generating worsening insulin resistance and severe hyperglycemia.
This puts people with diabetes (and prediabetes) at higher risk of severe complications from the virus, including kidney failure and acute respiratory distress syndrome — a form of respiratory failure caused by extensive inflammation in the lungs.
The algorithm
The authors say that effective management of blood sugar levels in people with diabetes could help prevent these complications. To facilitate this, they developed an algorithm.
They based the tool directly on patient observations. It places individuals into different risk categories based on blood sugar levels, the presence of obesity, level of insulin resistance, kidney function, and inflammatory markers.
The algorithm provides detailed treatment guidance for people without a prior diabetes diagnosis and those with known diabetes.
For critically-ill patients with severe hyperglycemia, it recommends administering an insulin infusion to lower blood glucose before transitioning to subcutaneous insulin.
The team also devised new ways to monitor patients’ blood glucose levels to reduce the risk of exposure to the new coronavirus. This included a new protocol for insulin delivery, which occurred every 6 hours coincident with a nurse check-in.
The authors say these efforts helped them effectively manage patients’ blood glucose levels without increasing the level of contact from nurses or other healthcare professionals.
Improved blood sugar control also reduced the risk of secondary infection and kidney problems. “This might help shorten ICU stays and lessen the number of patients that need a ventilator,” says first author Dr. Roma Gianchandani.
Next steps
The Michigan team’s findings add to the evidence that high blood sugar levels trigger inflammatory processes that lead to worse outcomes in people with COVID-19.
Their blood sugar management tool could also help other medical teams improve outcomes in patients with both COVID-19 and diabetes.
“[T]hese observations validate the importance of blood sugar management in COVID-19 patients and can serve as a guide or inspiration for other institutions.”
– Dr. Roma Gianchandani, first author and professor of internal medicine at Michigan Medicine
Although based on the observations of almost 200 patients, this study was not part of a clinical trial and, therefore, does not have a control group.
To confirm the utility of this new tool, there is the need for a larger, controlled study investigating how the algorithm influences the risk of complications, time to recovery, length of time in intensive care, and risk of mortality in patients with COVID-19 and diabetes. The researchers say they are looking forward to these next steps.
“Our team is looking forward to the next steps in confirming our hypothesis,” Dr. Roma Gianchandani says.
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