COVID-19 in people with diabetes: understanding the reasons for worse outcomes

Since the initial COVID-19 outbreak in China, much attention has focused on people with diabetes because of poor prognosis in those with the infection. Initial reports were mainly on people with type 2 diabetes, although recent surveys have shown that individuals with type 1 diabetes are also at risk of severe COVID-19. The reason for worse prognosis in people with diabetes is likely to be multifactorial, thus reflecting the syndromic nature of diabetes. Age, sex, ethnicity, comorbidities such as hypertension and cardiovascular disease, obesity, and a pro-inflammatory and pro-coagulative state all probably contribute to the risk of worse outcomes. Glucose-lowering agents and anti-viral treatments can modulate the risk, but limitations to their use and potential interactions with COVID-19 treatments should be carefully assessed. Finally, severe acute respiratory syndrome coronavirus 2 infection itself might represent a worsening factor for people with diabetes, as it can precipitate acute metabolic complications through direct negative effects on β-cell function. These effects on β-cell function might also cause diabetic ketoacidosis in individuals with diabetes, hyperglycaemia at hospital admission in individuals with unknown history of diabetes, and potentially new-onset diabetes.

People with diabetes with COVID-19 are at a greater risk of worse prognosis and mortality. Given the high worldwide prevalence of diabetes, these individuals represent a large vulnerable segment of the COVID-19 population. The poorer prognosis of people with diabetes is the likely consequence of the syndromic nature of the disease: hyperglycaemia, older age, comorbidities, and in particular hypertension, obesity, and cardiovascular disease all contribute to increase the risk in these individuals. The picture, however, is more complicated as it requires factoring in societal factors such as deprivation and ethnicity as well as factors that become relevant at the time that a patient with severe COVID-19 needs to be managed. Here, a physician has to account for not only the health status of the person with diabetes but also to balance carefully glucose-lowering treatments with specific treatments for the viral infection.

Once again, diabetes management in patients with COVID-19 poses a great clinical challenge, one that requires a much-integrated team approach, as this is an indispensable strategy to reduce the risk of medical complications and death as much as possible. Careful assessment of the many components that contribute to poor prognosis with COVID-19 in patients with diabetes might represent the best, if not the only way to overcome the current situation and enable our health systems to be ready to face any future challenges in a prompt and effective manner.

Finally, the inter-relationship between diabetes and COVID-19 should trigger more research to understand the extent to which specific mechanisms of the virus (eg, its tropism for the pancreatic β-cell) might contribute to worsening of glycaemic control and, in some cases, to the striking development of diabetic ketoacidosis or hyperglycaemic hyperosmolar syndrome, and possibly the development of new-onset diabetes.

Endocrinology and Metabolism: Open Access is a peer reviewed journal which focuses on the publication of current research and developments on the endocrine glands and its secretions with their coordination with metabolism and reproduction.

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Eliza Grace
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Endocrinology and Metabolism: Open Access
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