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“diabetic ketoacidosis (DKA) was a complication in almost half of cases among those with a positive COVID-19 test“

Very early during the COVID-19 pandemic it was reported that diabetes was an apparent risk factor for severe disease and poor outcomes. These data came from populations where most of those with diabetes had type 2. So one question was the effect of type 1 diabetes on COVID severity. Now a study has been published examining the effects of type 1 diabetes on COVID. A total of 33 persons across the United States with type 1 diabetes and COVID-19 confirmed by PCR test were surveyed. Another 31 with suspected COVID were also identified. The average age was 24.8 years. The symptoms of COVID were similar to expectations including fever, cough, fatigue, vomiting, shortness of breath, and aches. Interestingly, hyperglycemia was sometimes one of the earliest symptoms. Importantly, diabetic ketoacidosis (DKA) was a complication in almost half of cases among those with a positive COVID-19 test. This suggests that COVID-19, like some other viral infections such as severe influenza, can precipitate DKA. The research was published June 5th in the journal Diabetes Care (find the article at link1 or link2 ). If you or your loved one has type 1 diabetes, and develops symptoms of COVID-19, be sure to contact your diabetes doctor to help provide advice on how to prevent DKA. Fluids, carbohydrates, ketone checks, and extra insulin are very important in this regard. We remain on call 24×7 to assist.

Post by
Andrew Norris, MD PhD
Director, Pediatric Endocrinology & Diabetes
University of Iowa Stead Family Children’s Hospital

It has been well publicized that diabetes is a major risk factor for severe and fatal COVID-19. This is a frightening prospect for all with diabetes, but leads to questions of how this applies across ages and to type 1 versus type 2 diabetes. Some reassuring news arrived on March 25, when the International Society for Pediatric and Adolescent Diabetes published a brief, reassuring note (see this link) that front-line physicians in China and Italy had not observed severe COVID-19 in young persons with diabetes. However, specific data was not reported and the note was not peer reviewed per se. Now, a much larger and systematic study of persons with diabetes and COVID-19 has been published in the peer reviewed journal Diabetologia (link to the article). Over 1300 persons hospitalized with COVID-19 who had diabetes were studied. The study focused on the first 7 days of hospitalization for COVID-19, defining severe outcome as death and/or requiring intubation. Consistent with prior reports, severe COVID-19 was common among the patients with diabetes, with over 10% mortality by 7 days. The study found that higher BMI, older age, obstructive sleep apnea, and pre-existing vascular complications were strong predictors of severe COVID-19 in these subjects. Only 3% of the subjects had type 1 diabetes whereas 89% had type 2 diabetes. For those subjects with type 1 diabetes and younger age, the authors wrote that “our data can be considered reassuring for the majority of people living with type 1 diabetes. Indeed, there was no death in participants with type 1 diabetes younger than 65 years.” Although the study lends further reassurance that severe COVID-19 is not common among young persons with diabetes, especially type 1 diabetes, it was not suitably designed to fully answer the question. For one, there was no control population without diabetes studied. So, for example, although the risk of severe COVID-19 appeared markedly less among younger patients, this was only in reference to older patients. Another shortcoming for the purpose of understand the impact of pediatric diabetes on COVID-19 severity was that the youngest subjects were lumped into an age < 55 years category. Thus it is not even possible to know how many participants were pediatric aged. Despite these shortcomings, this study provides further reassurance that pediatric diabetes is not a major risk factor for severe COVID-19.

Addendum – September 22, 2020: Another reassuring report has just been published in the journal Diabetes Care. The authors report a community-based, retrospective review of hospitalization rates among adults with type 1 diabetes versus the general population. A total of 2,336 persons with type 1 diabetes were examined. The percentage of these persons hospitalized for COVID-19 was 0.21%. This was not statistically different than the rate among the general population in the region which was 0.17%. The authors conclude that type 1 diabetes does not increase the risk that a person will develop COVID-19 of sufficient severity to warrant hospitalization. The study was performed in Belgium. There are limitations that prevent full reassurance from this data. In particular, it is possible (or even probable) that persons with type 1 diabetes were more cautious in avoiding COVID-19 exposure than the general population, and this possibility was not examined.

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We remain available 24/7:

Please know that we are here for our patients. We and other centers have noticed that patients are often sicker than in the past when they come for medical care, presumably because they have delayed seeking care out of fear of contracting COVID-19. Importantly, please know that our medical center remains one of the safest places. All visitors are screened, including by temperature scanning cameras, and all staff maintain strict precautions. If you have questions or concerns about managing your endocrine condition, please contact us by phone/email/fax. If you are ill and might benefit from endocrine advice, we will work hard with you over the phone to help keep you from needing to come to the hospital. As of May 4, we have carefully re-opened our outpatient clinic for routine visits, in accordance with policies set by the State of Iowa. Additionally, we can conduct selected routine visits not requiring physical examination via video-chat. Contact us and we will help you arrange a clinic visit. Further information can be found at our official clinical website.

A reassuring note:

The healthcare community is learning more about the effects of COVID-19 on specific patients. You may have read that diabetes is a risk factor for severe COVID-19. Please know however that this data regards adults, mainly older adults. On March 25th, our European colleagues reported their impression that pediatric-aged patients with diabetes are not at increased risk of severe COVID-19. Likewise, initial data reports from the US have not mentioned diabetes as a pediatric-aged risk factor. On May 29, a peer-reviewed French scientific article reported similar findings. See this blog post for more details. It would be reasonable to assume the same is likely true for pediatric-aged patients with various endocrine disease, though we have yet to see any data. In any case, it remains important to be careful with your diabetes and endocrine medications. For youth with diabetes, aim to control your blood sugars as best possible, make sure to take your long-acting insulin / keep your insulin pump in good working order. The reason to keep your blood sugars in range as best possible is that persons with diabetes have a higher risk of needing to be hospitalized with COVID if their blood sugar have been running higher (see our review of this data). For youth with adrenal insufficiency, make sure to take your prescribed hydrocortisone or other steroids, and give stress dose steroids if ill etc as instructed. Keep your prescriptions up. Be sure to minimize exposures, practice social distancing, frequent hand washing, etc. See our hospital COVID-19 website for additional information.

COVID-19 increases risk of DKA:

Data has now been published showing that many persons with type 1 diabetes who develop COVID-19 will develop diabetic ketoacidosis (DKA). Our summary of the study can be found here (link). If you or your loved one has type 1 diabetes, and develops symptoms of COVID-19, be sure to contact your diabetes doctor to help provide advice on how to prevent DKA. Fluids, carbohydrates, ketone checks, and extra insulin are very important in this regard. We remain on call 24×7 to assist.

Adrenal insufficiency may increase COVID-19 risk:

Several endocrine sources have published opinions suggesting that adrenal insufficiency may predispose persons to severe COVID-19. Our summary of these opinions can be found here (link). If you or your loved one has adrenal insufficiency, it might be important to minimize COVID-19 exposures, wear protective masks, practice social distancing and frequent hand washing, etc. If you have questions or concerns, we are happy to discuss. If you think you have developed COVID-19, please know that we remain on call 24×7 to assist.