The Lancet: COVID-19 in people with diabetes: understanding the reasons for worse outcomes #covid19rftlks

Apicella, M. et al. (2020). COVID-19 in people with diabetes: understanding the reasons for worse outcomes | The Lancet | DOI:https://doi.org/10.1016/S2213-8587(20)30238-2

Summary

Since the initial COVID-19 outbreak in China, much attention has focused on people with diabetes because of poor prognosis in those with the infection. Initial reports were mainly on people with type 2 diabetes, although recent surveys have shown that individuals with type 1 diabetes are also at risk of severe COVID-19. The reason for worse prognosis in people with diabetes is likely to be multifactorial, thus reflecting the syndromic nature of diabetes. Age, sex, ethnicity, comorbidities such as hypertension and cardiovascular disease, obesity, and a pro-inflammatory and pro-coagulative state all probably contribute to the risk of worse outcomes. Glucose-lowering agents and anti-viral treatments can modulate the risk, but limitations to their use and potential interactions with COVID-19 treatments should be carefully assessed. Finally, severe acute respiratory syndrome coronavirus 2 infection itself might represent a worsening factor for people with diabetes, as it can precipitate acute metabolic complications through direct negative effects on β-cell function. These effects on β-cell function might also cause diabetic ketoacidosis in individuals with diabetes, hyperglycaemia at hospital admission in individuals with unknown history of diabetes, and potentially new-onset diabetes.

COVID-19 in people with diabetes: understanding the reasons for worse outcomes

The Lancet: Obesity and COVID-19: a call for action from people living with obesity #covid19rftlks

Caussy, C., et al. (2020). Prevalence of obesity among adult inpatients with COVID-19 in France|The Lancet Diabetes & Endocrinology8| 7|P. 562-564.

Most people who develop COVID-19 after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection present with paucisymptomatic and non-severe disease.1 However, approximately 20% of patients develop severe COVID-19 requiring hospitalisation, including 5% who are admitted to the intensive care unit (ICU).2 The ongoing COVID-19 outbreak has led to an unprecedented health crisis. Hence, it is crucial to identify individuals who are susceptible to developing severe COVID-19 and could require hospitalisation, especially in the ICU.Evidence is emerging that obesity-related conditions seem to worsen the effect of the virus. Studies from Chinese cohorts of patients with COVID-19 have identified several risk factors of severe COVID-19 including age, cardiomyopathy, and obesity-related complications such as type 2 diabetes and hypertension.3

Most people who develop COVID-19 after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection present with paucisymptomatic and non-severe disease.1 However, approximately 20% of patients develop severe COVID-19 requiring hospitalisation, including 5% who are admitted to the intensive care unit (ICU).2 The ongoing COVID-19 outbreak has led to an unprecedented health crisis. Hence, it is crucial to identify individuals who are susceptible to developing severe COVID-19 and could require hospitalisation, especially in the ICU.Evidence is emerging that obesity-related conditions seem to worsen the effect of the virus. Studies from Chinese cohorts of patients with COVID-19 have identified several risk factors of severe COVID-19 including age, cardiomyopathy, and obesity-related complications such as type 2 diabetes and hypertension.

Prevalence of obesity among adult inpatients with COVID-19 in France







Prevalence of obesity among adult inpatients with COVID-19 in France

JAMA: Using Insulin to Treat Poorly Controlled Type 2 Diabetes in 2020

Hirsch & Gaudiani (2020)| Using Insulin to Treat Poorly Controlled Type 2 Diabetes in JAMA. |323| (23)| 2419-2420| doi:10.1001/jama.2020.1303

JAMA has published the following as part of its Insights:

The prevalence of type 2 diabetes in the US has continued to increase, and, in 2015, was estimated to affect 9.4% of US adults.1 Recent American Diabetes Association (ADA) guidelines for diabetes treatment recommend choosing second-line therapies after metformin based on the presence of cardiovascular-and/or kidney-related comorbidities, risks of weight gain and hypoglycemia, and cost. There is little evidence or guidance regarding how treatment might differ based on how much a patient’s hemoglobin A1c (HbA1c) is above the treatment target after metformin is started. The guidelines recommend that patients who have established atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), or heart failure should be treated with a sodium-glucose cotransporter 2 (SGLT2) inhibitor or glucagon-like peptide 1 receptor (GLP-1R) agonist, irrespective of HbA1c. Exceptions include obvious signs of catabolism such as unintentional weight loss, an HbA1c higher than 10.0%, or glucose levels higher than 300 mg/dL, in which cases insulin may be considered. For patients who do not have ASCVD or CKD, other antihyperglycemic agents, such as dipeptidyl peptidase 4 inhibitors or thiazolidinediones, are recommended when risks for hypoglycemia need to be minimized. When mitigating weight gain (or promoting weight loss) is a primary objective, the use of SGLT2 inhibitors and GLP-1R agonists is suggested. When cost is the major challenge, the use of sulfonylureas and thiazolidinediones is emphasized. All of these recommendations precede those for initiating insulin therapy, which is recommended at or near the end of each treatment algorithm. When cost is the major consideration, basal insulin with the lowest acquisition cost is recommended, and this will usually be neutral protamine Hagedorn (NPH) insulin. Nevertheless, the overall magnitude of poorly controlled diabetes as manifested by HbA1c levels is not a factor in recommended treatment decisions until it exceeds 10.0%.

The full article is available from JAMA

University of Leeds: Research suggests drugs could reverse diabetes damage

University of Leeds | June 2020 | Research suggests drugs could reverse diabetes damage

Drugs developed to treat Alzheimer’s Disease could be repurposed to prevent – or even reverse – damage done to the blood vessels of people who are obese or have type 2 diabetes, according to research.

People suffering from a range of conditions called metabolic syndrome – which includes type 2 diabetes, high blood pressure, high cholesterol and obesity – have a stiffening of their blood vessels and that puts them at increased risk of a heart attack or stroke.

In a breakthrough, scientists at the University of Leeds and University of Dundee have discovered a key mechanism that triggers changes in the blood vessels, which can eventually lead to cardiovascular disease.

It starts when people begin to overproduce an enzyme called BACE1 which in turn creates a protein called beta amyloid.

Raised levels of beta amyloid are associated with damage to the surface lining of blood vessels, the endothelium. This disrupts the normal functioning of the blood vessels leading to high blood pressure and atherosclerosis, the build-up of plaque along the walls of the blood vessels (Source: University of Leeds).

Full press release from the University of Leeds

Elevated circulating amyloid concentrations in obesity and diabetes promote vascular dysfunction

Bespoke 3D insoles could significantly improve diabetes foot health

Diabetes.co.uk| July 2020 | Bespoke 3D insoles could significantly improve diabetes foot health

 


Newly developed 3D printed insoles could be the answer to preventing foot ulcers among people with diabetes, researchers have said.

 

A team from Staffordshire University has carried out a study on the product and found tailoring the stiffness of the cushioning insole, could significantly improve the foot health of the wearer by reducing pressure on the feet.

 

They found much of the insole’s success was linked to tailoring it around the person’s weight.

 

Lead study author Dr Chatzistergos, Associate Professor at the university’s Centre for Biomechanics and Rehabilitation Technologies (CBRT), said: “The optimum stiffness is clearly related to the patient’s body mass index (BMI). This study adds to our earlier findings and concludes that stiffer materials are needed for people with a higher BMI.”

 

These findings could be hugely significant as it is thought that around 2-2.5 per cent of the diabetes population has a foot ulcer in any given week. If left untreated they can sometimes lead to limb amputation.

 

The recently published research is thought to be the first trial which has looked at optimising cushioning for diabetic footwear as part of clinical practice.

 

A total of 15 people with diabetic foot disease were recruited for the study. They were asked to walk around in the adapted footwear, fitted with the bespoke 3D printed insoles.

 

They were specifically customised to fit across the surface of the foot bed and the material’s stiffness varied from very soft to very stiff.

 

Because of the positive study outcomes, the team are now focussing their efforts on trying to find a way to enable healthcare professionals to identify the individual cushioning needs of each person with diabetes thats they see.

 

Professor Nachi Chockalingam, Director of CBRT and co-inventor of the technology, said: “With numerous patients losing their limbs to diabetic foot disease, our research will help clinicians effectively manage this disease.” (Source: Staffordshire University)

 

Staffordshire University 3D printed insoles offers new hope for patients with diabetes

 

The research findings have been published in the Gait and Posture journal.

 

Highlights

 

Correct selection of cushioning stiffness significantly improves pressure reduction.

 

Patient specific selection can maximise pressure reduction in diabetic feet.

 

Patient specific optimum stiffness was correlated to the participants’ body weight.

 

Stiffer cushioning materials were needed for higher magnitudes of loading.

 

Further research is needed for clinically applicable optimisation of cushioning.

 

The full article can be requested from the Library & Knowledge Service

Warning over risk to diabetes patients amid imminent lockdown easing #covid19rftlks

Nursing Times|  June 2020 | Warning over risk to diabetes patients amid imminent lockdown easing

Not enough is being done to keep people with long-term conditions safe, according to a leading charity, which highlighted that people with diabetes make up 26% of UK coronavirus deaths.

Last week, the government announced plans to ease shielding measures, and to revise social distancing rules in England in an attempt to get the UK reopened following lockdown.

But the charity said it was concerned that steps to ease lockdown and reopen the UK risked leaving millions of people with diabetes “in the dark about how best to keep themselves safe”.

Backed by an open letter signed by more than 12,000 people living with and affected by diabetes, it is calling on the UK government to urgently respond to its concerns.

It wants the development of the national Covid-19 risk prediction tool to be fast-tracked, making it possible to assess a person’s individual risk based on different factors as soon as possible.

It is also calling for a “robust process” to be put in place to ensure that the advice a person is offered from the use of the tool will inform decisions about their own safety in their workplace.

Until that occurs, people who are vulnerable to serious harm, including those with diabetes, should have a right to stay working at home at this time, according to the charity.

In addition. there must be “robust” enforcement of guidance on employment protections for clinically vulnerable people and workplace Covid-19 risk assessments, said Diabetes UK.

Diabetes UK also stated that there must be “effective and proactive” communication of these measures so that people with diabetes know their rights.

It noted it had already written to the ministers three months ago but was yet to receive a response to acknowledge or confirm action would be taken to make the employment guidance more robust.

However, it said its position was backed up by the views of the public, based on a survey of over 2,000 people carried out in June.

It found 64% of respondents agreed that all UK governments needed to be doing more to ensure people with underlying health conditions were kept safe at work, rising to 75% among those over 55.

Chris Askew, chief executive at Diabetes UK, said: “The message from people with diabetes is clear; we want to go about our lives, but we’re deeply worried about our health as lockdown eases.

“The needs of people with diabetes are not being properly considered. People with long term conditions cannot, and should never have been the government’s blind spot. Lives are at stake.”

He added: “We reiterate our calls, which we have been doing for weeks, to ensure that people with diabetes are not forgotten, and that additional measures and safeguards are in place.” (Source: Nursing Times)

Warning over risk to diabetes patients amid imminent lockdown easing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Guidance for clinically vulnerable people, and employers, remains unclear, warned Diabetes UK, which is calling for better risk assessment before those with diabetes return to workplaces.