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Managing Diabetes in Patients with COVID-19

Jun 25 | 2:00 PM

As per CDC, case surveillance data reported through April 2020 indicated that COVID-19 patients with underlying conditions, such as diabetes, were six times more likely to be hospitalized and twelve times likelier to die. This makes learning best practises very important for doctors to manage diabetes effectively in Covid-19 and Covid-19 in diabetic individuals.

good evening today's speakers dr bansi sabu and dr rucha mehta and all the delegates it gives me immense pleasure to welcome you all on day two of kovicon let me introduce today's speakers dr bansi and dr rucha dr bansi sabu is a qualified diabetologist and endocrinologist with his md degree in medicine and he also has distinction of phd in the phenotyping and genotyping of young diabetics in india he also had held many important prestigious positions like being the president of the research society of studying diabetes in india that is called rssdi he also was a president of indian diabetes associate society currently he is the secretary of diabetes india and he held a huge uh gathering uh on virtual international conference with almost 50 delegates who are speakers who are the international speakers and he is a prolific organizer he as well as dr rucha the next speaker they are one of the members jointly write the guidelines for the indian people for the diabetic people in the india we welcome dr bansi and the next is dr rucha mehta she's also had her mbbs degree from km hospital mumbai then she went to usa for her md degree in medicine as well as md in diabetes and endocrinology from university of texas she worked as assistant professor in university of los angeles and she's out there for number of years her main interest is in pathophysiology of diabetes pre-diabetes and obesity currently she's practicing as endocrinologists diabetes molecular metabolic physician as well as the obesity physician in the clinic called admob edmo stands for the endocrinologist meteorologist metabolic physician as well as the obesity consultant at apple hospital we would like to have more questions and answer with two of our speakers and the topic is also managing diabetes in covet 19 time so let's begin with dr bansi sabu yes more vulnerable to getting the infections so i will not say that they are more vulnerable to infection but once they get the infection the severity for the covalent infection will be more so i mean the hospitalization the morbidity the mortality all those things will be more with the persons with that but yes theoretically also if i say the diabetics are comparatively immunocompromised and there is a possibility of getting more infection also but at the same time i will not say that all diabetics will get more infection if they keep the appropriate behavior that is very important kobe appropriate behavior they should follow regularly and they should get vaccinated as early as possible and at the same time the social distancing and masking will definitely help them to get less infection but those patients are uncontrolled diabetes that is very important because here there is a difference between a controlled diabetes and an uncontrolled diabetes so uncontrolled diabetes from the infection point of view getting hospitalization more morbidity and even mortality is higher with the uncontrolled diabetes that they should take care of that sugar part dr rucha if the patient is having diabetes but it is well controlled how does it make difference between the non-diabetic counterpart good evening everybody and thank you for having me on this wonderful platform and such an appropriate discussion so really we have lots of data now if we were having this discussion one year ago i could not appropriately or confidently answer this question but now just recently we've had a very nice paper in from dr kunti's group itself they looked at it was not a meta-analysis but a review article more but they looked at all the studies because the data is still incomplete in some of this uh diabetic studies we look at comparing controlled versus uncontrolled diabetics as you just said and as dr bansi also rightfully pointed out that if diabetics have appropriate behavior not only will they have less chance of contracting the disease but also they'll come out of this successfully so clearly dr kunti and group have shown in this particular article that if your diabetic patient is well controlled and then he contracts covered 19 he has less chance of getting hospitalized or having complications such as ending up in the on ventilators or even further complications like renal failure and other end organ disease multi-system disease so yes it will make a huge impact if you're well controlled versus being uncontrolled also the future complications that we worry about post covered complications that we are all facing right now those would also be less in our well-controlled diabetic patients it's easier to talk but still there is a difference between the diabetic patients and completely non-diet is the diabetic controller yes yes but still for the control diabetes you still have they have a in compared to completely a person who is non-diabetes in the same paper they have divided into three parts non-diabetic diabetes who are controlled and unconscious so both of you want to say that even if you are controlled diabetic you still at a higher risk than the non-diabetic counter yes definitely important comorbidity this is not outdoor then what are the complications that you encountered um all patients who are diabetic uh during hospitalizes in this pandemic one is that itself is the sugar is becoming very uncontrolled those patients who are getting hospitalization or even those who are getting the infection what i have seen in last one and half years almost like last 15 months that many of our patients who are even not got getting infection but because they are at home they are worried that they will not go outside they may get infection but sometimes they are not taking care there are 50 percent of the patients who are taking care of themselves too much and 50 of them are not taking and they are not checking they are not monitoring they are at home they are eating more even they are thinking they are not going out so they are not eating outside food but in the home also they can eat more and they are not controlling their sugar so their sugars are very very uncontrolled there are couple of patients or you will find some of the patients who will say that i could not get my medicine because most of the medicines also stop closed down or it was a lockdown situation so these are the patients they will develop severe hyperglycemia but we are talking of the patients who have developed infection once they develop infection again uh patients are getting admitted they are more and some of the times what i had seen primary care physicians or physicians who are admitting them they are you know so much taking care of the covet part sometimes they are forgetting the comorbidity and many a times we are seeing that their sugars are becoming very much uncontrolled neither they are continued on the medicine which were continued for them or nor they were started the insulin or intensive therapy as per the guideline and this is clearly you know in next five days ten days or even some of the patients were put on the steroid that sugar will become very very high so i mean this is related to one part of it there are patients who are type one there are patients who are on basal bonus insulin therapy also and we are just forgetting they are type one and basal part is completely stopped and they have developed diabetic ketosis also so i mean covered infection had really increased in some of the patients significant hyperglycemia and we had seen some of the complications related to hyperglycemia itself and i'm not talking about the covet part and other problems but this is just related to the sugar only right yeah is there anything to add i mean i think he's covered it all and several questions arise from what he has just mentioned you asked about complications so clearly the covert virus as he mentioned likes to attack the pancreatic beta cells itself we think so seeing worsening of the hyperglycemia new onset hyperglycemia in patients who were previously non-diabetic seeing pancreatitis per se so we are seeing complications in fact you know we are starting to link everything to the virus now if once you've had uh it's interesting right from top to bottom as we are well aware it's even caused this thrombosis as we call it not a real you know atherosclerotic block but thrombosis that we are seeing in the post covered era also but during the infection itself ranging from a mild feeling of malaise to a really bad feeling of fatigue in the in patients who are hospitalized with the worst thing of hyperglycemia really high oxygen requirements in the ones who are affected in the lungs so that is something that we all are aware how we had to battle with the oxygen shortage just a few weeks ago so certainly all of these complications ranging right from you know top to bottom practitis is one of the big things that we've been encountering at apollo where i practice so we are seeing quite a few of these patients over here question or your comments about the pancreatitis how many pancreatitis patient did you see and could it be by chance because of some of the drugs that the patient might be raising the anti-diabetic drugs that yes i mean uh yeah so we are careful as to what molecule what agents we are using and for treatment of diabetes because we are worried about still using the uh when these patients get sick they're not eating well so sglt2 inhibitors we are avoiding the pancreatitis as i mentioned we have almost seen in a polo i'll tell you but not the data we've seen about three to five patients per month presenting with post corporate pancreatitis and who have also been young patients lean ones and they have presented with uncontrolled sugars as well as with um you know the spankititis now is this due to the the drugs or is it due to the virus certainly there have been enough papers now that have linked even acute pancreatitis uh seen along during the coveting infection um within grazed amylase lipases including acidosis renal failure we are seeing the whole thing so there have been more case reports and retrospective cohort studies they were having the very high light rays in the mind also but one patient who was first time detected with diabetic ketosis and pancreatitis a young patient and even the antibody also came the positive so everything was there so it was a pancreatitis and otherwise also a diabetic known patient of diabetes they have otherwise also had high risk of developing pancreatitis many of them may have gallstones they may be on the anti-diabetic therapy which may also lead to the pancreatitis or virus itself can lead to the pancreatitis so there are multiple reasons and i'm sure maybe in another few months we will have few more data from all across the world as far as pancreatitis is concerned in india we don't i know publish so much data about the real world you know like rucha may have a few patients you may have a few patients i may have a few patients and all across the country there are many but you know the problem is we may not publish it uh no discussion of diabetes and co would be complete without bringing nuclear mycosis so how much was the difference in the first and the second view about the macro microsystems and what do you think what are the reasons for getting more macro microsees in our part of the globe than the other parts so certainly i think in the first wave i don't think we actually even worried about in india at least about much mycosis i did not see or hear of any cases even from our civil hospital and you know dr bunsey may know countrywide because he's talking to people all over uh but the second wave has left us with our you know jaws dropping is when we were in medical school or even an endocrine residency they said you'll you know you'll be fortunate that's the word they used to see two or three cases of mucor mycosis in your career and now at you know there were times at a given time and even in a smaller branch of apollo that we have on sg highway we used to have four to five cases of post covered muco and in the main hospital itself we have seen more than 100 cases and as we are aware in the civil hospital over here which is the government hospital quite a few so certainly why are we seeing these increased cases in india this is all of course speculation or some of with some scientific reasoning behind it is number one uncontrolled diabetes access to care or not going to get medical care or getting your covert treated right on time not realizing when you have to really go for it and waiting till the very last minute patients who were on high dose steroids and steroids have been used inadvertently more than necessary you know not what the data suggests a lot of steroid use and lastly also high oxygen use patients who needed high oxygen amount uh and the industrial oxygen use was another big thing that we spoke about that has been debated also of course and that's one thing we could understand that this acute infection have the problem with more those who have non-communicable disease and one of the co-morbidity was that you know the diabetes obese patient history of cbd cancer and ckd patients were dying more so i could not understand even at that point of time i was trying my level best as an rss president and we had talked with ima also we should increase the awareness about these ncds and at least for diabetes which is a a condition which can be monitored more frequently and we can keep under control if we will do that probably the persons who will develop the infection they will have less morbidity and motivation the covid virus itself also change the immune system of the body the uncontrolled sugar will make it more immunocompromised and over and above the use of the steroid and which will not be under control will mean someone too much immunocompromised and then there is a possibility of getting this nuclear infection will be very high it is not like that in first wave it was not there completely in second wave it was there and you can see again the data from the western part was slightly higher in compared to the east maybe the reason that we developed the second wave first here then we realize there is a mutual microsis which is occurring and then this news is spread all over the country so i don't see that these people why they could not get so many patients with looker micros probably they started thinking now that sugar is in more problem because people were you know using the steroid like anything and they were not just controlling the sugar level so this is one very important reason why the patients were developing nuclear microsis and not keeping a very tight control of the sugar yes this deadly quadrate covalent infection itself over uncontrolled diabetes then they were actually steroid and then then they were getting the nuclear microscope i mean this all four is very important and still for the next third day we should monitor sugar more tightly keep the sugar under tight control so at least whenever the wave of koi or any other infection will come probably these diabetic patients can be prevented from these complications what you said makes sense dr bansi that even the kovid infection itself could be one of the reasons for more macro mycosis maybe we had a kovid infection with a variant which predisposes to such infections because see we hear so many of patients who are neither hospitalized neither had steroids and even when at the time of recovery recovering and they got the infections and maybe because it said as dr ruta said in the initial part that there is a localized thrombo inflammations and that produce the local necrosis and maybe the nasal mucosa if there is a local thrombosis and that produces the necrosis and that invites because because mycosis in the environment it's a ubiquitous organism fungus and that's already in the present and may be present in large number but they need the right atmosphere to proliferate so maybe kovid associated micromicrosis also may be one of the reasons with a particular strain that more is prevalent in our part of the globe isn't it i fully agree ac2 receptors were in a big discussion in the earlier part of the pandemic so what are your comments uh dr rucha about the ac2 and diabetes and kovid 19. you know when we first understood it all we knew is that here's your score v2 this is the kovi 2 variant we're talking about that is binding to your h2 receptor and this is expressed right over there now again once it gets into your system it also will affect your rust system so you have to understand that because ace 2 also catalyzes your angiotensin 2 conversion to angiotensin one and so your entire axis is going to affect get affected that is how it might have a far-fetching effect uh on your vascular system on causing a lot of these other things that you are seeing and the release of all these inflammatory markers that you see further on down the pathway because the h2 receptor is present we know beyond besides the lungs now we also know the brain the liver heart pancreas intestine kidneys i mean kidneys most obviously so we know that it can spread to all these other organs and infect the ace to expressing cells at local sites and that's how it causes the multi-organ damages what we are simply put trying to uh you know explain that would be what i would say now once it affects your ass system it's going to cause a variety of things you know it just depends on how what the person has an underlying co-morbidity so we really have to worry about this entire mediation in fact that's why treatment is being targeted to the spikes like a protein because if we can blunt the spike like a protein binding to the h2 receptor in some way because this is a specific binding functional receptor for cells in the outdoor patients having 19 mild infections compared to the non kovid infections and during hospitalization so how to manage as far as the targets are concerned and what are the ways you will monitor them so the tight glycemic control is always invisalized it is not from the kovid or non-kovid as far as the patient who is completely normal and uh either he is non-coveted or a covet-infected patient and the most of the international guideline is talking about the hb1c target less than seven while american association of clinical endocrinology and idf is more aggressive in keeping the events target of less than 6.5 but indian guideline and currently the rss guideline is also talking less than seven is enough for that but as i told you it has to be in this life the person who can keep even see of less than 6.5 without hypoglycemia good enough if somebody is at the risk of developing hypoglycemia having hypoglycemia unaware or having a history of cardiovascular disease then we can keep even seven less than 7.5 that is good enough if an elderly patient frail more risk of hypoglycemia even keeping your evency of less than eight is also good so i mean this is what we want to have a target for most of our diabetic patients and to keep a good control will make them definitely better as far as covet infection is concerned but once they are in hospital we are not talking of a1c then we have to move from events to the regular monitoring of these patients blood glucose monitoring the blood glucose the fasting sugar if we can keep less than 110 but not never more than 130 then we have to intervene for these patients and keeping that target is good enough that is fixing the fasting first that we should do first thing post meal me it is not just post lunch it has to be post breakfast post lunch and post dinner preferably less than 160 but never more than 180 so try to keep the sugar which is between 80 to 180 we have the time in range that is you know more than 70 percent of the time if somebody is keeping the sugar between 70 to 180 it is comfortable john but in a patient who is getting hospitalized we should not get sugar level more than 180 because they are more prone to develop infection that is what in hospital hyperglycemia guideline our target is to keep the sugar less than 180 once the patient is in the room the anti-diabetic agents whether to continue the same agent which they were on or should we change that's a question important once they are icu the preferred choice is always an insulin if they are on nil by mouth they are on ventilator they are erratic food habits or patient is already serious they are on ionotropic agent i don't think there is any anywhere any controversy as far as for these patients only insulin insulin insulin either iv insulin preferably iv insulin or they could be on basal bolus therapy also multiple daily insulin injection that is what we do but the patients who are micromoderate infection and they are in the room what we should do for the different oral anti-diabetic agents there are multiple such papers with published and recently even the dapaglia flows in their study which has also published which have shown that even dapper can be also continued before that we were thinking that sglt2 by giving them will it increase more uh genetical or microtic infection and patient will go in the you know the fluid loss will be there whether we should continue these type of molecules or not but out of all these molecules we found that glypton is better because no much side effects metformin can be continued but preferably in a lower dose again the patient is going with the dysfunction that's the problem glitter zone have a fluid retention problem sulfonylurea can lead to hypoglycemia erratic hypoglycemia can occur they might not be eating regularly these patients so different oral anti-diabetic agents again you have to indulge the patient that what type of therapy would you like to continue but definitely insulin is very safe and which we can use basal boneless therapy is a choice of therapy whenever a person is getting hospitalized yeah and i think we will have to keep a close watch on the renal and liver functions when we are giving the oral hypoglycemic drugs or oral anti-diabetic drugs are the obese patients more vulnerable or if they get it are they having the more infections or more complications or longer hospital stay or more oxygen requirement your experience about the obesity and kovid infections and the review of literacy no so yes absolutely you know quite clearly we are now well aware that obesity increases your chance for contracting covert 19 infection um not only that you know i would like to say that not just contracting the infection but also at the same time the chance of getting complications just like a diabetic they have a higher chance of getting hospitalized higher chance of requiring steroids ventilation and ending up with mortality and morbidity similarly also an obese patient so the reasons we think are similar to in the diabetic patients is that they have seem to have some problem in your immune responses so not um you know we know that there are several stages in your immune pathway and for some reason just like the diabetic patient the obesity milieu we know that there is something going wrong in both the adaptive and the innate immunity so we really do worry about as to does this patient how does he recover not only that does the vaccine work in him in fact there was a study even quoting that probably in these patients uh the obesity in these obese patients they are more likely to spread the infection and hence might need a longer quarantine than your routine patients because they are higher chance of spreading the virus well uh as compared to their thinner counterparts so something to be really really you know worrying about is why are these obese patients and so hence preventing them from becoming diabetic is what would be more important we have several studies now that have shown that obesity was an independent risk factor after even you know neutralizing for all of the other studies the most important one is by dr simonet atar and colleagues that reported the need for increased mechanical ventilation at a bmi cutoff of more than 35 but i'm sure as dr bansi pointed out we started getting studies for india our bmi cutoffs might be a bit lower because we know we get metabolic syndrome uh or pre-diabetes obesity related things at much lower um you know and so si do it all also conducted another meta-analysis wherein they showed that even bmi more than 25 so this was sort of a cohort more similar to the asian population also had an also increased risk now the two biggest risk factors for covid19 besides diabetes was age and bmi you know older people have more complications obese people have more complications and even in the people who are younger now if you're less than 35 but if your bmi is more than 30 so the younger people who are obese have a higher chance so that strengthens that uh whole data point again that you really need to work on losing your weight and similarly in other asian studies also a threefold increase increase in critical illness with covert 19. so we have a lot of things now that are suggesting that um losing even some weight or simply watching your diet maybe being healthy and taking staying fit active exercise attention to exercise might help to pro you know you can't lose weight in a day so you want to do at least whatever is healthy very well covered dr bansi uh how often you encounter type 1 diabetic patients having the cold infections and leading to hospitalizations and the complications so many of my type 1 diabetic patients had developed the infection it's not like that as usual other persons but the type 1 diabetes here i am talking of type 1 adult i am not talking of type 1 children because that too many of my patients are type 1 children also so type 1 diabetic patients adults are equally at the high risk of developing the infection as they are having diabetes as we had seen many of type 1 diabetes they are not very well controlled the glycemic variability is also very high their events is also very high and they had developed a lot of complications also we have patients of type 1 diabetes adult type 1 when they get admitted sometimes they are again you know a physician may think that it's like a type 2 diabetes and they had not given the basal insulin as i told you two of my patients who are admitted and actually they have developed diabetic ketosis just because the basal insulin was stopped and they were on the every time the sugar is to be checked and the insulin was to be given so as such i tell all my type 1 diabetic patients whenever you are getting admitted at least you tell three times to your doctor that you are a type 1 you cannot be stopped with the insulin even when you are sick the basal insulin is never to be stopped by any means and they may develop any other in fact any other complication like any other type 2 diabetic patient but luckily i have almost like 14 or 15 patients who are admitted and none of them have a severe problems and none of them patients were on ventilator none of the patients were dying also so when we have around 14 patients to whom i was in touch and i was trying to control the sugar on telephones dr rucha would you like to add your experience i completely agree that it's not that our type ones are spared you know you would sometimes uh dr bansi i used to wonder that because it's type 1 is an autoimmune disease do we here will they not be affected as much if their sugars are well controlled but i think the only reason we hear less about type ones getting it's less than that you know overall 10 of people have type 1 whereas 90 of the diabetic world has type 2 diabetes yeah so that's why we are not hearing so much about the type one but the ones who have it we really need to be you know sympathetic and helping in fact i currently have you know a patient she's type one and she got covered and she was pregnant so we are all just keeping our fingers crossed at the nine month mark as to what's going to happen she did get covered yeah so i mean certainly i mean this second wave has uh really been uh horrendous it's been scary for no patient group has been spared not the you know not type one not type two and similarly we have heard about a lot of pregnancy related covert 19 and also complications and including mortality so that has been challenging and pregnant uh women of course we worry about more because they have you know there is a child also to worry about we are taking care of two lives but fortunately i think they are caught early on and we are able to treat them with simple medications and they don't get into complicated things again what determines the complications would be pre-existing co-morbidity so presence of obesity related conditions like pcos diabetes an older mother who is already high risk those would be the things that might predispose them to complications yeah so you know we do worry about i mean several things so number one is of course what you worry about is loss of the pregnancy you know that the mother is going to miscarry or have um or might require medical termination the child may not survive if she gets into complications so of course the decision is um depending on this to say the mother always but you know if the child is at seven or eight months we could deliver the child so that way we can have we doing justice but it may not be possible if the patient is already on steroids or on a ventilator or something of that sort so definitely this is something to worry about so number one is loss of the biggest thing is loss of life to mother loss of life to the child um thirdly we are seeing all this the ards or pregnancy related ards that we see in these pregnant women so that's also very very important to worry about now say post pregnancy so during pregnancy all the complications that we see in our routine patients of course we see the same thing happening multi-organ failure all of those things but what about the child that's what we always worry about so can the child get covered through the mother is something that we always talk about and really uh that's not necessarily true that the child of the pregnant mother always gets covered and we've seen that from so many deliveries so far uh less than five percent of reported cases uh in pregnant women whose child also had it do they get antibodies and what happens to these children um you know again these are all one in four of the babies who are born to cover 19 mothers do get sick and are admitted to neonatal icu so there is something happening some autoimmune reaction that is causing them to have pre-term birth order and that might be the indication for admission to neonatal icu so i think sort of you know kind of these are some of the things that i could think of from the literature review i don't know i don't know but i mean also a person who is pregnant and if she develops the kobe it's a name as 99 percent of them are going to recover but still it is a very big psychological trauma whatever the complication which rucha had already talked but many of our patients and their relatives are friends and you know some of them were already pregnant and they developed the covet infection it had created a lot of stress in the family we know that the outcome will be again in 1995 or even 99 will be the normal even many of them will not require even hospitalization also but those patients who will require hospitalization definitely their course of treatment will be one the loss of the neonate or the child pregnant lady whatever that all complication can occur as with anyone but before that there will be a lot of mental stress to the family that had happened many times which i have encountered more than around 30 40 of my patients and their relatives not directly i'm talking of diabetic female i'm talking of my relatives friends or some of my patients uh relative or their daughter-in-law or sanil i mean their daughter they were pregnant and they were having a lot of mental stress because of that so what are the chances that newborn would get coveted from the mother so i mean that data she had already talked that you know around one fourth of them had developed the covet infection and they required neonatal hospitalization also so that was a from the data point of view but i don't know from the india more paper will be talking about and what will happen to these neonates we have developed a neonatal covate infection what will be their future outcome i think time will tell or once we will get few more papers probably we will able to answer it better or neonatologists one of the delegates want to know dr bansi that how do we adjust the dose of metformin uh in patients with diabetes and kovid any specific precautions we have to take care for metformin in the full dose we know that it can be given up to two gram per day when we want to do a reduced dose particularly patients with myogeneral dysfunction when the egfr is between 60 to 90 you may reduce it and preferably you would like to give it around one gram per day as kovid also increases the inflammation insulin resistance so many of the time i would not like to decrease the dose of metformin unless definitive there is an indication like the ah there is a renal dysfunction is happening or the person is acutely sick where i don't want to give the patients with metformin or there is a hypoxia which is also one of the important reason where i would not like to give the patients metformin because of hypoxia increases the chances of lactic acidosis so these are the condition where i will not go for the dose reduction rather i will stop the metformin that's a better way of doing it rather than reducing the dose because one day when you are doing the reduction of the dose and second day you find that this patient is deteriorated more what will you do so you have more safer anti-diabetes and why you would like to continue a molecule which can be a problem later on and you have to reduce so as soon as you find some patient to whom you have to hospitalize because hospitalization indication was one of them was the hypoxia oxygen saturation is getting down i think first thing you can do is you can stop the metformin for these patients another question is that if the patient had diabetes is to steroid-induce diabetes would be the what will be the choice of drug insulin or the oral hyper-glance agents because probably most of the patients with steroid-induced hyperglycemia it is insulin is the choice but one very important thing they require more of a to control post meal hyperglycemia the steroids normally leads to more of a post breakfast post lunch and post dinner so these patients don't put on the premix insulin i mean that's not a choice of therapy they will develop more hypoglycemia now don't just put the the those of short-acting insulin by checking the sugar four-hourly rather than give them insulin before meals and that's very important and try to title it with post meal sugar also so i mean you are giving five minutes or ten minutes before breakfast make sure that post breakfast sugar is coming under control so if you are not checking for breakfast you will not do paired monitoring you will not able to know that whatever the amount of insulin which you had given yesterday actually corrected the sugar properly or not so do pre meal sugar give the insulin and check post meal sugar also that weather whatever the amount of insulin which you had given had actually control the sugar also or not fasting if it is not controlled then give the basal insulin also to control fasting just if you are having the pre breakfast 216 it means the fasting is also not controlled give them a basal insulin to keep the fasting around 100 20 110 or less than 130 and then give the bolus injection which is a short acting insulin preferably analog if it can be given because that can be taken just before the meal give it and check it again after two hours that yes your sugar is not going more than 180 that should be our way of you know managing the sugar when person is on a steroid but that is the choice of therapy you may use if some of the patients who are on a very low dose steroid actually the therapy is steroid in kovid is like seven days a course there is nothing like a tempering dose or continued for a prolonged period of time but yes there are patients whose sugar is not very much increasing then you can think of giving them alpha glucosidase inhibitor or short acting glinites also like repugnant or netting clinic that may control their sugar or they were already very well controlled diabetes only on metformin only on that these are the patients who can be controlled otherwise the insulin is the choice in fact i was going to suggest the same that because theoretically steroids are inducing hyperglycemia because of the production of insulin resistance so giving insulin is not as good a choice as probably the controlling insulin independent hyperglycemic uh choices what do you say dr rocha he completely have a doctor he's covered it very well that in your patients who are on steroids or who are hospitalized no questions asked you know whether we have insulin resistance or not only insulin can be given safely and effectively so number one if they are hospitalized then definitely and also when they go on these high dose steroids our medicines really fall short very often and we end up having to use meal based insulin as you mentioned the postprandial hyperglycemia is high but in the outpatient setup and you're mild to say just you know lower moderate cases of covert 19 when you're managing them at home yes it would help you are still able to continue oral agents and you can use insulin sensitizers generally metformin we are staying away from pioglitazone during these covert times though it's a great molecule but uh your if the patient has corbin 19 we prefer not to use it just for the edema and water retention we may not know and there'll be confusion in the picture so yeah certainly otherwise using an insulin sensitizer as soon as you can safely how do you manage these diabetes and what were your experience about managing diabetes after covalent infection is clear patient is sent home so we are seeing now a lot of patients who are coming to us again in the opd again on the telephony consultation on video consultation on online consultation they had kobe they were having diabetes either it was controlled uncontrolled on steroids without a steroid they were pre-existing diabetes newly detected diabetes we will be talking about all those things but now they are to be treated as one uh you know like you are treating a diabetic patients who had come to you if it is a type 2 diabetes typical whatever the therapy was going on you have to escalate but one very important thing which i think again we should talk these patients more about the education if my patient was admitted with nine espionage in here come back now the sugar is all okay but now what i will do for these patients not only i am going to control the sugar but i will put another my 10 minutes to talk about that you know you had not kept your sugar control when you admitted what was your sugar and why you could not get it controlled in last one year you are lucky that you could not get severe problem that was fine but that does not mean you should not keep your sugar under control and this is i think an opportunity for we clinician to teach our patients better to educate them more about the glucose monitoring to educate more than uh the tight control the benefits of tight controls which they will get every time i mean this was one part kovid has gone all it was they were having covet we may get third wave we may not get but tomorrow some other things may happen and otherwise also the benefits of tight glycemic control will be always there not only for any acute infection to have them but also for the chronic complication which they can have because of diabetes they will be also prevented by keeping tight glycemic control so i mean this is an opportunity for the clinician to teach or educate these patients for better diets glycemic control yeah i would like to just uh add to this that whenever the patient comes after with irrespective whether he has diabetic or non-diabetic i think we should be looking for diabetes as screening because of one of my personal patients who had been with me for 10 years not diabetic she used to take steroids off and on for her asthmatic bronchitis but she was not clearly diabetic she suffered from covet infections she was at home she did not receive diabetes she came for a routine checkup and she feels that she was not all right nothing and i took ecg and it found it to be lbb so naturally when patient has new onset lbbbn patient is uncomfortable and breathless we think of cardiac conditions so i asked for all the investigations including the random blood sugar ecg soda lbb so the cardiology say that we'll have to take her for angiography next day troponin was negative but the sugar came to be 800 and patient had no symptoms even retrospectively when asked her symptoms she had mildly symptom of some dryness that's it but no clear cut symptoms so in fact i use the term happy hyperglycemia like happy hypoxia of course there is nothing happy about it but she had no symptoms so what we meant was that there can be a silent hyperglycemia also like silent hypoxia in many of our patients and we have got to look for and surprisingly just starting insulin in infusion next day our sugar came down and her lbb also disappeared so hyperglycemia with metabolic disturbance electric disturbances might be producing many electrolyte changes and electrocardiographic changes also and she was definitely saved from angiography at that point of time and her hba1c turned out to be 18 for the first time that i ever saw this high so how often you find the blood sugars in the range of 600 and 700 in your patients after kovid recovery so very interesting case doctor madhuri but i mean what i suggest that each and every one of us we should not miss an any opportunity forget about the covet part any patient who is coming for to any primary care physician sugar is to be tested in the clinic because we are having almost uh 15 to 25 percent of our adult population and age is is increasing above the age of 40 the data shows that in some of the urban area it is like more than 30 percent of our patients are diabetic and 50 percent of them are actually not knowing they are diabetic so this is an an opportunity for us to diagnose them now post covet we will be i thought i will be we will be discussing about the covariant diabetes separately because there are patients who are not having pre-existing diabetes first time they were detecting diabetes during kovid or postcovid it is the kovid virus which has caused the hyperglycemia is it the stress which has unmasked their sugar or it is the first time they were detected because they were actually diabetes but they were not knowing they were diabetes it is steroid induced hyperglycemia so there are multiple reasons even we are thinking that this virus can also lead to increase in auto antibody formation which can also lead to the beta cell destruction which can become you know they can become even type 1 diabetes also it could be a type 2 diabetes because we know that ace2 receptors are also there at pancreatic beta cells and pancreas so that could be the also reason for them to have a covered hyperglycemia and there are many papers which are getting published and nature and there are some publication which are they are talking that what could be the mechanism how new onset of covalent hyperglycemia can we call a new terminology covered hyperglycemia and a new onset of type 2 diabetes in covet patient but definitely there is inflammation already a patient might be having insulin resistance and it could be a masking effect of you know insulin resistance followed by beta cell failure and they develop frank diabetes also but your case was very interesting but we see patient with 600 700 800 i had seen but these patients were already on steroids so the patient was ah maybe i had seen even a non-diabetic was put on a steroid and patient was in 700 800 but patient had not come in my opinion these patients were in hospital and i got the reference to control them we had the patient who were already pre-existing diabetes who develop 800 my own patient who was at home but diabetic and he was on the steroid and he had developed the sugar of hatred so i have many patients whose sugar had gone more under 570. as far as events is concerned i had seen some patients with even she was more than 17. i mean at that point of time the lab had not given the one exactly range it is more than 17 is written so i have some questions and i had kept their reports also with me that with more than 17 it is different very important question remains is the efficacy of vaccines in patients who are having diabetes that is one and is there any difference in the different type of vaccine giving the different types of efficacy in patients with diabetes and very often we get questions that should diabetic patients be vaccinated so all these questions pertaining to vaccine and diabetes and kovid so i will tell only one that all patients should take all every one of us should take lexington so that's number one there's no contraindication the diabetes should not take uh for different vaccine i i will not comment here regarding that a whether a person with a diabetes will they get the similar result yes that's in a question because the uncontrolled diabetic patients may have its immunological or immune modulation that may be the reason for them not to have so much antibody so my request to everyone that we should keep our sugar well controlled and at the same time the vaccination will definitely help them to have a good antibody formation also but still uh i would like uh rucha comments also about the same so i just want to add back on that case that you had dr desai because we are getting tons of patients who are coming in now with this sudden random sugar as you mentioned that they have not felt and they are just experiencing fatigue and we realize when we check the sugar it's still high and these were previously non-diabetic sometimes very often um in fact i myself had a 40 year old very lean patient who presented with the shortness of breath and we found he was in he had myocarditis and his blood random sugar in clinic was more than 500 is all the monitor said and we admitted him and uh this is the interesting the thing to mention this case again is these are the patients i will not start on dpp4 inhibitors and sglt2 inhibitors because you know as glt-2 inhibitors we don't start and someone we think might have an insulin opinion as dr bansi mentioned the virus is inducing antibodies or attacking the beta cells and causing lack of insulin and if you put an sglt2 you would precipitate ketoacidosis so you don't want to use in this case and the second scenario dpp4 we know are linked to pancreatitis if there is any suspicion of a pancreatitis before you rule that out you don't want to start it right away of course that was a myth but we still would worry about if you're going to use insulin in these patients more than you know for sure now for the vaccine yes i'm with dr sabo we need to be you know everyone needs to get the vaccine especially our diabetic patients so that is a no-brainer young old does not matter does not matter if they have underlying fatty liver they have underlying ckd they have to get clearance from their doctors and you know unless there's a very highly compelling indication not to get it everybody needs to be getting the vaccine and i will follow in the lead of dr bunci as to not to comment which vaccine is better yeah i just wanted to emphasize the same that maybe that outcome of any of this vaccine may be different in diabetic but all the more reasons that they are more vulnerable so they have to be vaccinated if we have that is why they are one of the members who included in the priority list of vaccinations diabetics should be vaccinated by all means and one of the last questions before i ask you to give your closing remarks is how the kovid has changed your practice how often you resort to tele medicine and tele health to your patients who are stable whether it is diabetic or non-rabbit patients so a lot i think a lot you know in fact i think we are going it has changed the way we uh live our life this has been you know a life changing last year and a half for a lot of us so it's not just uh how we are treating our patients patients also were initially very scared to come in and even now we have only fifty percent of our patients who want to really come to clinic so that's still a huge drop in numbers and they prefer to do video consultation and it's very convenient uh it's comfortable you're able to manage them and we do worry about sometimes we may miss because we're not examining them but yes it has certainly changed my practice greatly and so this is the same situation you know everywhere we are having now more of a online consultation but one very important thing doctor this is that we were doing actually online consultation most of our patients were phoning and they were taking but now they understood the importance of the online consultation and they are getting the proper you know information their prescriptions and everything so and still a lot of patients are not coming and we also don't want now because we also understood before few years uh we used to tell that why don't you come and tell us but if they are otherwise stable not having any other problem you also tell them if we can do the online consultation and we are happy they are happy you know everything is fine with that

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Dr. Neil Nunes & 1132 others

SPEAKERS

dr. Rucha Mehta

Dr. Rucha Mehta

Endocrinologist | Apollo Hospitals International Limited | Gandhinagar

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dr. Banshi Saboo

Dr. Banshi Saboo

Chief Diabetologist & Chairman of Diabetes Care & Hormone Clinic at Ahmedabad

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dr. Mahadev Desai

Dr. Mahadev Desai

Senior Consultant Physician | Ahmedabad

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dr. Rucha Mehta

Dr. Rucha Mehta

Endocrinologist | Apollo Hospitals Internatio...

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dr. Banshi Saboo

Dr. Banshi Saboo

Chief Diabetologist & Chairman of Diabetes Ca...

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dr. Mahadev Desai

Dr. Mahadev Desai

Senior Consultant Physician | Ahmedabad

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