Medication Alterations Might Be Necessary in COVID-19 Patients With Diabetes

Diabetes patients with serious COVID-19 cases requiring hospitalization also might need to have their drug regimens altered. Find out what the issues are, and which drugs should be re-considered or discontinued.

TORONTO – Medication changes might be required in diabetes patients being treated for COVID-19 infection, according to a new study.

Noting that those patients are at increased risk for bacterial, parasitic and viral infections, an article in Endocrine Reviews, a journal of the Endocrine Society, discusses some of those necessary therapy alternations in hospitalized patients.

Complicating matters is that diabetes often is co-morbid with obesity, which is emerging as an important comorbidity for disease severity with the novel coronavirus.

"We reviewed how the pathophysiology of diabetes and obesity might intersect with COVID-19 biology and found key shared pathways and mechanisms linked to the development and treatment of type 2 diabetes," explained study author Daniel J. Drucker, MD, of Mount Sinai Hospital in Toronto. "Cells within the lung and gut are major sites for coronavirus entry and inflammation. These cells express key proteins like Angiotensin Converting Enzyme 2 (ACE2) and Dipeptidyl Peptidase-4 (DPP4) that are also present in the development of type 2 diabetes."

The study points out that, while ACE2 and DPP4 are important physiological regulators of glucose homeostasis, little clinical evidence is available showing that drugs targeting ACE2-or DPP4-related pathways produce differential harm or benefit in the context of human coronavirus infections. The article notes that DPP4 inhibitors and GLP-1R agonists could exert anti-inflammatory actions and have been successfully used to control glucose in hospitalized patients.

“However, there is insufficient experience with these agents to suggest they might safely replace insulin in critically ill subjects with coronavirus infection,” Drucker adds. “Hence, the extensive historical experience with the use of insulin, bolstered by increasing adoption of continuous glucose monitoring, supports the ongoing use of insulin as the agent of choice in the management of severely ill subjects with diabetes and coronavirus infections.”

The article recommends that, in hospitalized patients with deteriorating renal function, the use of SGLT2 inhibitors and exenatide should be re-considered or discontinued, and metformin and sulfonylurea dosing might also need to be reduced or stopped, explaining, “The rapid flow of new clinical information stemming from the SARS-CoV-2 epidemic requires ongoing scrutiny to understand the prudent use, risks and benefits of individual glucose-lowering agents and related medications.

Because of insufficient experience with diabetes and pregnancy in subjects with SARS-CoV-2, no tailored therapeutic recommendation were made for that group, although the report notes that “modified screening guidelines for gestational diabetes have been proposed in the context of SARS-CoV-2 for individuals with limited access to regular clinics.”

Drucker also cautions that the expression of ACE2 within the exocrine and endocrine pancreas underscores “the need for vigilance in consideration of whether pancreatic inflammation reported in some individuals with SARS-CoV-2 infection may contribute to the exacerbation or development of diabetes in a subset of acutely ill patients.”