COVID-19 can be especially dangerous in patients with diabetes, causing severe and potentially life-threatening complications. It’s important for people with diabetes who get COVID-19 to continue to manage their condition through the illness, but there’s one medicine that, according to researchers, may do much more harm than good. If you take it, check with your doctor…
While there isn’t enough data to show whether diabetics are more likely to get COVID-19 than the general population, it’s becoming clear they are more likely to develop severe complications from COVID-19.
For instance, viral infections like COVID-19 can increase inflammation, or internal swelling, in people with diabetes, and that inflammation could contribute to more severe complications.
People with diabetes who contract COVID-19 also face a greater risk of developing the potentially lethal condition diabetic ketoacidosis (DKA), caused when illness or certain conditions prevent cells from receiving enough glucose to keep them working. As the body’s cells fail to absorb enough glucose, they compensate by metabolizing fats instead, creating a buildup of acids called ketones.
Now, researchers are warning that the use of a common diabetes drug was seen to trigger a particularly rare form of DKA for some 2 diabetes patients infected with COVID-19…
Diabetics with COVID-19 advised to skip SLGT2i use
Based on results of a recent observational study, researchers are urging ill patients to stop their use of a popular class of diabetes drugs called sodium-glucose cotransporter 2 inhibitors (SGLT2i), especially if they suspect they have been infected with COVID-19.
Medicines in the SGLT2i class include canagliflozin (Invokana), dapagliflozin (Farxiga) and empagliflozin (Jardiance). They are available on their own as well as in combination with other diabetes drugs such as metformin. SLGT2i medicines lower blood sugar by prompting the kidneys to release excess glucose from the body through the urine.
A rise in a particular type of DKA called euDKA at Boston-based Brigham and Women’s Hospital during the COVID-19 pandemic has led researchers to hypothesize that diabetes patients on glucose-lowering drugs like SLGT2i may be at increased risk for euDKA when they contract COVID-19.
EuDKA is more difficult to diagnose than DKA because it is characterized by lower blood sugar levels. People suffering from euDKA are usually in a state of starvation that can be triggered by illnesses like COVID-19 that cause vomiting, diarrhea and loss of appetite. This state of starvation can be compounded by the diuretic effect of SGLT2i drugs.
Researchers at Brigham studied five unusual euDKA cases brought into the hospital within the span of two months, three of which occurred in one week, in spring 2020. The five cases represented a significantly higher incidence of euDKA compared to that of the previous two years, when Brigham saw fewer than 10 euDKA cases in total.
All five of the recent euDKA cases occurred in COVID-19 patients who were taking SGLT2i. Three patients were discharged to rehabilitation facilities, one was sent home, and one, a 52-year-old male with acute respiratory distress syndrome, died.
“We have the background knowledge of recognizing that SGLT2 inhibitors can cause DKA and euDKA,” says corresponding author Dr. Naomi Fisher. “Our report reinforces that if patients are ill or have loss of appetite or are fasting, they should pause their medication and not resume until they are well and eating properly.”
Ways in which COVID-19 heightens euDKA risk
The authors of the study also suspect that COVID-19 may particularly exacerbate euDKA risk by binding to insulin-producing cells on the pancreas and having a toxic effect on them. In studies of the earlier SARS-CoV-1 virus, patients were found to have increased blood sugar.
“It’s been posited through other models that the virus may be preferentially destroying insulin-producing cells,” Dr. Fisher says.
Another way in which COVID-19 may be increasing DKA risks is by producing high levels of immune-response-related proteins called cytokines. Dr. Fisher observes these high levels of cytokines are also seen in DKA and speculates there may be some synergy between the inflammatory pathways.
Similar reports of heightened euDKA incidence have emerged from other institutions.
The study authors encourage patients and physicians to halt SGLT2i use in the event of illness, already standard practice for the most commonly prescribed diabetes drug, metformin. Dr. Fisher says it’s often a very short course of the drug and advises patients to continue to monitor their blood sugar. If the illness is prolonged, or if their blood sugar is very high, they can then speak to their doctor about other ways to control it.
“We’re hopeful that with widespread patient and physician education, we will not see another cluster of euDKA cases amid the next surge in COVID-19 infections,” Dr. Fisher says.
Keeping watch for symptoms
If you have diabetes and you suspect you may have contracted COVID-19, call your doctor immediately. When you call, make sure you have your most recent glucose and ketone readings available, track and report your fluid consumption and be clear on the symptoms you’re experiencing. Some common symptoms of COVID-19 include fever or chills, cough, sore throat, congestion or runny nose, shortness of breath or difficulty breathing, loss of smell or taste, fatigue, muscle or body aches, headache, nausea, vomiting and diarrhea.
Make sure you ask your doctor questions on how to manage your diabetes, especially if you’re taking an SLGT2i. If you do stop your medication, there are plenty of natural alternatives type 2 diabetics can try to help manage your blood sugar. However, it’s important to discuss them with your doctor first, especially if you have COVID-19. Together, you and your doctor can come up with a plan that will keep you balanced and help you recover from COVID-19 safely.
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Euglycemic Diabetic Ketoacidosis with Covid-19 Infection in Patients with Type 2 Diabetes Taking Sglt2 Inhibitors — AACE Clinical Case Reports
Sodium-glucose Cotransporter-2 (SGLT2) Inhibitors — U.S. Food and Drug Administration
How COVID-19 Impacts People with Diabetes — American Diabetes Association