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A COVID-19 and Diabetes Update From Anne Peters

Hi. Today I’m going to give you a few updates on COVID-19 and diabetes.

The Good

First, we’ve learned that telemedicine works for helping people with diabetes. We always thought it would work, but now we know it works. We have studies from Spain, Italy, the United States, and many other countries that show we can provide equivalent or even better care through telemedicine than in person.

Now, this means we’re good at managing glucose levels as long as we have data. We have to be able to do true remote management, which means we need to be able to get the data from our patients in order to help manage their blood sugars. I think it’s very important to prove that we can do that and do that effectively.

We’ve also shown that we can use continuous glucose monitors (CGM) in the hospital. Ever since the emergency ruling passed from the FDA allowing CGM to be used in the inpatient setting, a number of hospitals have implemented CGM, and they have shown that it’s quite helpful. I’m hopeful that we’ll be able to continue using CGM in hospitalized patients.

The CDC originally said that all people with diabetes were in the highest risk group for doing poorly with COVID-19. Now, the CDC has divided the types of diabetes into two groups. They still say that people with type 2 diabetes are in the highest risk category, but those with type 1 diabetes are in a slightly lower risk category.

For both groups, I think most of the available data suggest that better glucose control is associated with better COVID-19 outcomes, particularly in terms of lower risk for hospitalization, intubation, and death. Good control matters, and that’s something I’ve spent a lot of time in the past few months trying to help patients achieve.

The Bad

Now, there are some bad things. One of the things that really worries me is that telemedicine is great in all sorts of ways, but we’re missing certain important findings. There was a very good retrospective chart review study published recently in the Journal of the American Podiatric Medical Association that looked at patients who were seen by a foot and ankle surgery service during the first 8 months of the pandemic.

They found that any level of amputation was 10.8 times higher during the 8 months of the pandemic than before the pandemic, and the risk for major amputation increased with an odds ratio of 12.5. They also showed that there was an increase in the severity of infections.

This is very serious because it means that patients who have lower-extremity issues aren’t getting seen soon enough, and they’re not getting referred to care soon enough. We’re really not doing a good enough job here. I think patients are afraid to come in to medical practices, but it’s very important that we see our high-risk patients, evaluate their feet, and refer them as needed.

People have also been afraid to see the ophthalmologist. I think people consider going to the ophthalmologist risky because they have to get pretty close to the person who is looking at their eyes.

A study from Israel found a 50% decrease in people coming in for their required anti-VEGF injections. These are people with very serious eye disease who aren’t following up. We really need to make sure that our patients follow up with their eye healthcare, because otherwise they can end up with serious sequelae.

Finally, there was a recent article published in The Lancet Psychiatry that isn’t only about people with diabetes, but I thought it was interesting. They found a relationship between people who have had COVID-19 and a subsequent increase in psychiatric diagnoses.

These are people who had not had a prior psychiatric diagnosis. The most notable diagnoses were anxiety, mood disorders, insomnia, and depression. The authors compared this with patients who were hospitalized for other causes — like influenza or another virus — where they didn’t find this increase in psychiatric diagnoses.

They also found that this was a bidirectional association, with a higher incidence of psychiatric diagnoses in the year before the COVID-19 diagnosis. Having a psychiatric disorder may increase your risk of developing significant COVID-19 infection, and having had COVID-19 can increase the risk for psychiatric diagnosis. This is important to be aware of in addition to the stress and strain of dealing with this pandemic, which I think is increasing psychiatric issues and diagnoses across the board.

Our Response

I think we need to continue with telemedicine; it works great for people with diabetes as long as we have their data. We can keep people healthy at home and out of the office if we have the data with which to manage them.

However, we must encourage our patients to come in to the office if there is any concern that there’s something we need to physically examine. People need to feel like our offices are safe and that they can come there without concern. We really need to have patients come in who need to be examined.

We also need to encourage adherence with all necessary appointments. I take time out of every telemedicine visit to review whether the patient has gone to the ophthalmologist, cardiologist, or whoever else they need to see so we don’t have a further increase in the harm that this pandemic is causing.

Finally, the mental health toll of this pandemic is impacting everyone, so we should do our best to connect people with appropriate resources to help them.

This has been Dr Anne Peters for Medscape. Thank you.


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