DR MRS LUCY MUNGAI

PAEDIATRICIAN/ENDOCRINOLOGIST

DEPARTMENT OF PAEDIATRICS AND CH

UNIVERSITY OF NAIROBI 07-04-2020

COVID19 AND TYPE 1 DIABETES

MELLITUS

DIABETES AND INFECTION

Patients with diabetes mellitus (DM); infections more often than

those without DM

The course of the infections more complicated

Increased prevalence of infections-defects in immunity; decreased

functions (chemotaxis, Phagocytosis, intracellular killing)

DIABETES ANS INFECTION…..

Increased adherence of microorganisms to diabetic cells.

Described in Candida albicans infections.

Possibly the carbohydrate composition of the receptor

plays a role in the adherence.

Carbohydrates such as heparan sulfate have been reported to

play a crucial role in the entry or budding of viruses

Recently, the viral surface proteins have also been reported

to bind to carbohydrates on host cells

DM AND INFECTION

Carbohydrates function as receptors for virus entry.

Negatively charged carbohydrates on many types of cells and

tissues such as sialic acid and heparan sulfate, are common

viral receptors.

Orthomyxovirus, polyomavirus, reovirus, coronavirus,

paramyxovirus and parvovirus recognize sialic acid as a

receptor.

Hyperglycemia

Possibly triggers higher stress condition;

Release of hyperglycemic hormones-glucocorticoids and

catecholamines, leading to increased blood glucose levels and

abnormal glucose variability

Retrospective study from Wuhan;

10% of the patients with DM and COVID-19 suffered at least

one episode of hypoglycemia (<3.9 mmol/L)

Hypoglycemia has been shown to;

mobilize pro-inflammatory monocytes

Increase platelet reactivity -higher cardiovascular mortality in

patients with diabetes

COVID19 AND DIABETES

Remains area of investigation how exactly the inflammatory

and immune response occurs in diabetic patients,

whether hyper- or hypoglycemia may alter the Covid19

virulence, or the virus itself interferes with insulin secretion

or glycemic control

DM AND COVID19

Hyperglycemia and insulin resistance;

promote increased synthesis of glycosylation end products

(AGEs)

pro-inflammatory cytokines, oxidative stress,

stimulate production of adhesion molecules that mediate

tissue inflammation

leads to a higher propensity to infections, with worse

outcomes in patients with diabetes

WHY DM PATIENTS

Hyperglycemia;

has been linked to inhibited lymphocyte proliferative

response to different kinds of stimuli

impaired monocyte/macrophage and neutrophil functions

abnormal delayed type hypersensitivity reaction and

complement activation dysfunctions.

BEFORE COVID19

Previous in vitro studies; pulmonary epithelial cells exposure to

high glucose concentrations

increases influenza virus infection and replication,

augmented vasculature permeability and collapsed alveolar

epithelium.

patients with uncontrolled diabetes generally present a

significant reduction in forced vital capacity (FVC) and

forced expiratory volume in one second (FEV1),

WUHAN

A Chinese study compared 39 SARS-CoV patients without

previous diabetes, who did not receive steroid treatment,

with 39 matched healthy siblings

20 of the 39 covid19 patients developed diabetes during

hospitalization. Since immunostaining for ACE2 was strong in

the pancreatic islets,

It was suggested that covid19 might have damaged islets

cells and caused acute insulin dependent diabetes mellitus

DM AND COVID

It is known that older age and the presence of DM,

hypertension, and severe obesity (BMI ≥ 40 kg/m2) increase

morbidity and mortality in patients with COVID-19

It is unknown whether DM independently contributes to this

increased risk.

However, plasma glucose levels and DM are independent

predictors for mortality and morbidity in patients with SARS

Susceptibility

Potential mechanisms that increase the susceptibility for

COVID-19 in patients with DM include:

i. higher affinity cellular binding and efficient virus entry,

ii. decreased viral clearance,

iii. diminished T cell function,

iv. increased susceptibility to hyperinflammation and cytokine

storm syndrome,

v. presence of CVD

RODENTS AND DM

Increased expression of ACE2 in the lung, kidney, heart, and

pancreas in rodent models of DM

Insulin administration attenuates ACE2 expression

Hypoglycemic agents such as glucagon-like peptide-1 (GLP-1)

agonists (liraglutide) and thiazolidinediones (TZDs;

pioglitazone), ACE inhibitors, and statins upregulate ACE2

Circulating levels of furin, a cellular protease involved in

facilitating viral entry by cleaving the S1 and S2 domain of

the spike protein, are elevated in patients with DM

Children, DM and Covid19

In general, a better regulation of the DM leads to an

improvement of these cellular functions.

some microorganisms become more virulent in a high

glucose environment.

the increased LEVELS OF HBA1C in diabetics may be

responsible for the increased stress in the cells-prone to

infection

DURING ILLNESS

Follow the sickday management guideline

Blood sugar every 3-4 hours during the day and every 1.2

hours at night

Rehydrate

Insulin to be adjusted according to blood sugar

Can give sugary food if there is hypoglycemia

All diabetes patients should know how to contact the

diabetes Health Care Professional

Sick day management

Use correction factor to lower the blood if there is

hyperglycemia

Use blood ketones to guide on management

Use regular insulin or insulin analogues

for boluses, no role of premixed insulins and basal insulin

Do carbohydrate counting

Maintain Hydration

Home made soups with no cardohydrates

but with salt

Those who can; lemon water, lemon

ginger

NOT PLAIN WATER

URGENT specialist advice with possible

referral to emergency care must be

obtained when:

Fever or vomiting persists and/or weight loss continues,

suggesting worsening dehydration and potential circulatory

compromise.

Fruity breath odor (acetone) persists or worsens / blood

ketones remain elevated >1.5 mmol/L or urine

ketones remain large despite extra insulin and hydration.

The child or adolescent is becoming exhausted, confused,

hyperventilating (Kussmaul breathing), or has severe

abdominal pain.

KETONEMIA

There are three ketones: acetoacetate,

acetone, and beta-hydroxybutyrate.

Urine ketone strips measure acetoacetate

(AcAc) and acetone (if the strip contains

glycine)

Blood ketone strips measure

betahydroxybutyrate (BOHB), the

predominate ketone in DKA.

KETONEMIA

In response to insulin therapy, BOHB levels commonly

decrease long before AcAc levels do.

The prolonged ketones in urine after the patient has

improved can result in confusion when there is clinical

improvement.

Persistent ketones in urine leads to additional insulin

administration when it is no longer needed, either at home

or in emergency rooms/hospital settings due to a desire to

“clear” the urine ketones and can lead to hypoglycemia

NoteThe most common mistake made by health

care providers and caregivers who are unfamiliar with diabetes is to recommend the complete omission of insulin because "the child is ill and not eating," thus increasing the risk of frank diabetic ketoacidosis (DKA)

NEVER STOP

INSULIN

INJECTION

COMPLETELY

SUMMARY

Prepare all diabetes patients for sick day

Make sure they have insulin and stripes

Incase of an illness check blood sugar more frequently

Adjust the dose of insulin but not discontinue

Check ketones in urine and blood

Keep hydrated

Follow the giudeline of Covid19 prevention and treatment

Keep your diabetes team informed

know when admission is needed

THANK YOU