Year : 2021 | Volume
: 14 | Issue : 2 | Page : 169--172
Challenges and management of type-1 diabetes in COVID-19 pandemic
Department of Pediatrics, KLE University's Jawaharlal Nehru Medical College; Department of Diabetes, KLES Dr. Prabhakar Kore Hospital and MRC; Thalassemia Day-Care Centre; Collaborative Child Response Unit, Belgaum, Karnataka, India
Dr. Sujata Jali
Professor and Head of the Department of Pediatrics, KLE University's Jawaharlal Nehru Medical College, Belgaum - 59010, Karnataka, India; Consultant Pediatric Diabetologist, KLES Dr Prabhakar Kore Hospital and MRC, Belgaum - 59010, Karnataka
|How to cite this article:|
Jali S. Challenges and management of type-1 diabetes in COVID-19 pandemic.Indian J Health Sci Biomed Res 2021;14:169-172
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Jali S. Challenges and management of type-1 diabetes in COVID-19 pandemic. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Jun 17 ];14:169-172
Available from: https://www.ijournalhs.org/text.asp?2021/14/2/169/317396
Coronavirus disease (COVID 19), a highly transmissible disease, originated in China in December 2019 and spreads to 200 countries prompting the World Health Organization to declare it as a pandemic on March 11, 2020. The number of cases <20 years are susceptible to COVID-19 infection and account for 10%–20% of the diagnosed cases according to Women and Child Welfare department. COVID-19 disease can cause severe manifestations in people with comorbidities particularly with diabetes, where outcomes may be poor.
COVID-19 is a multisystem inflammatory state. It is theoretically possible that any organ with the angiotensin-converting enzyme 2 receptors in abundance might be a source of some clinical manifestation. Endocrine and exocrine dysfunction of the pancreas may be a result of the same. Viral infections are well known to develop pancreatic autoantibodies, leading to type-1 diabetes (T1D) in genetically predisposed individuals and coronaviruses identified as incriminating pathogens in the TEDDY study.
Most of the research and outcomes are done in type-2 diabetes with COVID-19. T1D constitutes about 5%–10% of all diagnosed cases of diabetes, and its global incidence is increasing at about 3% every year. The total number of T1D in children and adolescents between 0 and 19 years in India is 95,600, and several new cases (incidence) of T1D per year are 16,800. Management of T1D requires a multispecialty approach and needs continuous care. In a country like India, with its high-density population and a significant number of people with T1D, the risk of COVID-19 infection is high.
Although lockdown is effective in controlling this virus community transmission, the lockdown has many challenges being faced by the children and adolescents living with T1D during this lockdown listed below.
Diabetes self-management (DSM) is essential to improve or maintain glycemic control, minimize the risk of complications, and improve quality of life. DSM management includes multiple insulin injections with appropriate technique, blood glucose monitoring regularly, healthy diet, physical exercise, problem solving, and healthy coping. DSM helps adolescents become self-reliant in the management of diabetes and gives them confidence. Unfortunately, people on insulin with poor glycemic control or recurrent hypoglycemia require self-monitoring of blood glucose at least 4 times/day more so during sick days. The regular supplies of glucose meter strips to children and adolescents are affected due to lockdown.
Insulin injections are essential for the survival of children with T1D mellitus (T1DM), and they require multiple injections daily. Many of these children are depended on a regular supply of insulin and glucose monitoring equipment, which are supported by programs free insulin treatment (FIT) program initiated in our hospital by the National Diabetes Foundation, Changing diabetes in children, and life of a child. This supply can be disrupted due to the closure of hospital and travel restrictions.
Sick day management in diabetes is an important aspect that must be taken care of during the pandemic. Infections can reduce oral intake and increase the release of stress hormones which can alter the blood glucose levels, leading to risk of both hyperglycemia, hypoglycemia, and diabetic ketoacidosis (DKA).
Access to vegetables, fruits, and other grocery required to prepare a healthy diet is reduced, and the healthy eating plan of these children may be affected. Along with this drawback, there may be reduced availability of junk foods, which will impact the insulin requirements. There is generally high consumption of carbohydrate-rich foods in resource-limited settings.
Since the children are home bond and have restrictions of outdoor physical activity, due to closure of gyms, parks, and play grounds. This may lead to uncontrolled diabetes, psychological disturbances, and change in sleep pattern.
Due to nonavailability of intensive care unit (ICU) beds in emergency situations in the current COVID-19 epidemic will result in panic and may worsen their glycemic control with consequent DKA. Management and diagnosis of comorbidities such as hypothyroidism, diabetic neuropathy, retinopathy, and nephropathy may be delayed.
Adolescents with diabetes have a 3 folds increased risk of psychiatric disorders such as depression, anxiety, suicidal attempts, and eating disorder. These disorders can be further aggravated by the lockdown due to the closure of schools and colleges.,
Many families can suddenly reduce their earnings due to the restrictions and expenditure on the child's medication.
Management of Type-1 Diabetes Mellitus during COVID-19 Endemic
Increase in the incidence of T1D development has been related to coronavirus infection, and thus, practitioners have to be aware of the development of T1D in this epidemic. Furthermore, there are reports where DKA symptoms were masked by COVID-19 symptoms. Therefore, COVID-19 infection might increase the risk of DKA in known cases or delay in diagnosis of new-onset T1D leading to severe DKA. The reason could be that doctors preoccupied with COVID-19 might not consider DKA in the differential diagnosis with Kussmaul's respiration and a fruity odor in the breath.
There has been an increase in chloroquine and hydroxychloroquine for the prophylaxis and treatment of COVID-19. However, both these agents can cause hypoglycemia in patients with and without diabetes. Therefore, close monitoring for hypoglycemia and their insulin dose adjustment is required.
The following messages should reach the family and T1D children through a dedicated helpline managed by specialists.
Parents and children should learn sick day managementDo not stop insulin completely and continue the usual carbohydrate intakeManagement of DKA: T1D patients should keep in contact with their treating doctor if they have symptoms of vomiting lasting more than 2 h, nausea, vomiting, abdominal pain, breathlessness, drowsiness, and confusion. If blood glucose (BG) is more than >270 mg/dl check for urine ketones with ketone strips every 2–4 h, if blood ketone meter is not available.
Intravenous (IV) insulin infusion is standard for DKA management but may be difficult nowadays, as it often requires admission to the ICU. Due to the current COVID scenario, wherein ICU admission is difficult, the patient should be guided to manage mild-to-moderate DKA without ICU bed with subcutaneous (SC) insulin. In uncomplicated DKA hourly or 2-h SC, rapid-acting insulin analog (insulin lispro or insulin aspart) or SC regular insulin is an alternative if rapid-acting analog is unavailable. This is safe and may be as effective as an IV regular insulin infusion. Starting dose is 0.8–1 unit/kg/24 h, and the dose is divided by 6 to provide an insulin dose injected every 4 h. Doses are increased or decreased by 10%–20% based on the blood glucose level before the next insulin injection.
Plenty of oral fluids should be advised to prevent dehydration. If the glucose level is falling below 180 mg/dL, sugar-containing fluids should be considered to decrease the risk of starvation ketosis. Patients should be advised to maintain BG between 110 and 180 mg/dL. Once the patient is able to take orally and DKA subsides basal insulin should be initiated.
Restriction in food supplies and closure of markets during the lockdown might force people with DM to alter their dietary habits. A balanced diet containing proportionate nutrients with adequate protein intake is important. Carbohydrate 50%–55%, fat 30%–35% (up to 20% total energy), protein 10%–15%, and fiber-age in years + 5 grams/day should be advised.
In collaboration with local health authorities, local support groups and nongovernment organizations, arrangement for regular milk, vegetables, fruits, and other essentials during lockdown will be beneficial. Children and adolescents should follow information booklets and the dietician's advice related to healthy diet.
Hypoglycemia can be a significant issue amid the ongoing pandemic. Signs and symptoms of hypoglycemia such as tremors, anxiety, sweating, chills, clamminess, irritability, confusion, tachycardia, dizziness, hunger, nausea, and pallor should be made aware to the T1D children. Skipping of meals should be discouraged as this predisposes to hypoglycemia. In case of a hypoglycemia, one should eat or drink 15–20 g of fast-acting carbohydrates such as soft drinks, honey, or sugary candy. For those with resources, check blood sugar levels 15 min after treatment and if they are still under 70 mg/dL, eat or drink another 15–20 g of fast-acting carbohydrate, and recheck the blood sugar level again in 15 min, repeat these steps until the blood sugar is above 70 mg/dL. Now, concentrated sugar tablets are available.
Sick Day Management
Every child and adolescent with T1D should be educated about sick day management protocols. Vomiting reduces appetite leading to hypoglycemia. Stress of illness increases counter-regulatory hormone response causing hyperglycemia. Frequent monitoring of BG is recommended. If hypoglycemic, administer glucose and reduce the dose of the next insulin. If hyperglycemic/kenotic, administer 5%–20% of the total daily dose as short-acting insulin.
Regular physical exercise 30–40 min/day is recommended. Other alternative physical activity programs can be undertaken within the safe confines of home by educating them through online tools and social media. Motivate children for indoor plays and exercises. Yoga and meditation may be practiced with involvement of family members.
Psycho-Social Issues and Stress Management
Patients should utilize telecommunication in discussing psychological problems with their caregivers during these times. Caregivers should also inquire about the mental health of patients. Social support can also help alleviate the distress imposed by the COVID-19 disease and its multifaceted effects. Appropriate family involvement and diabetes support groups can help.
People having T1DM should be provided with 24/7 technical support for sick day management. Dedicated customer care helpline may assist them in better T1D management, thereby reducing the risk of DKA and subsequent hospitalization.
Steps Were Taken in Our Diabetes Center to Manage 350 Children with Type-1 Diabetes Mellitus during the COVID-19 Pandemic
We have given a 24/7 helpline number to all the children with T1DMTwo days of the week, we do online consultation free of costWe supply free insulin under the FIT programWe have recognized persons from certain areas to collect insulin from our center with cold chain for distribution in that surrounding areasWe send educative titbits through short message service messages to all the children 2 times a week regarding care and managementOur hospital is opened for out-patient department and admissions 24/7We have managed many DKA and new-onset T1D during COVID-19 epidemics.
Our motto is that no child should suffer from a lack of insulin or die during the COVID situation.
Children with T1D are at a higher risk of contracting COVID-19 and having worsening symptoms if they contract infection. Prevention is mainly through meticulous diabetes self-care and general prevention practices for COVID-19. In addition, it is essential to reemphasize health education on glycemic control to minimize the devastating effects of COVID-19 among populations.
|1||World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19; March 11, 2020. p. 4. WHO Director General's Speeches. Available from: https://www.who.int/dg/speeches/detail/who-directorgeneral-s-opening-remarks-at-the-media-briefing-on-covid-19-11-march2020. [Last accessed on 2021 May 25].|
|2||Liu F, Long X, Zhang B, Zhang W, Chen X, Zhang Z. ACE2 expression in pancreas may cause pancreatic damage after SARS-CoV-2 infection. Clin Gastroenterol Hepatol 2020;18:2128-30.e2.|
|3||Lönnrot M, Lynch KF, Elding Larsson H, Lernmark Å, Rewers MJ, Törn C, et al.; TEDDY Study Group. Respiratory infections are temporally associated with initiation of type 1 diabetes autoimmunity: the TEDDY study. Diabetologia 2017;60:1931-1940. doi: 10.1007/s00125-017-4365-5. Epub 2017 Aug 2. Erratum in: Diabetologia 2018;61:254.|
|4||DIAMOND Project Group. Incidence and trends of childhood type 1 diabetes worldwide 1990–1999. Diabet Med 2006;23:857-66.|
|5||International Diabetes Federation. IDF Diabetes Atlas. 9th ed. Global Picture. 2019. p. 36-72. Available from: http://www.diabetesatlas.org. [Last accessed on 2021 May 27].|
|6||Adu MD, Malabu UH, Malau-Aduli AEO, Malau-Aduli BS. Enablers and barriers to effective diabetes self-management: A multi-national investigation. PLoS One 2019;14:e0217771.|
|7||Danne T, Phillip M, Buckingham BA, Jarosz-Chobot P, Saboo B, Urakami T, et al. ISPAD Clinical Practice Consensus Guidelines 2018: Insulin treatment in children and adolescents with diabetes. Pediatr Diabetes 2018;19 Suppl 27:115-35.|
|8||Kumar KM, Saboo B, Rao PV, Sarda A, Viswanathan V, Kalra S, et al. Type 1 diabetes: Awareness, management and challenges: Current scenario in India. Indian J Endocrinol Metab 2015;19:S6-8.|
|9||Fadini GP, Morieri ML, Longato E, Avogaro A. Prevalence and impact of diabetes among people infected with SARS-CoV-2. J Endocrinol Invest 2020;43:867-869. doi: 10.1007/s40618-020-01236-2. Epub 2020 Mar 28.|
|10||Laffel LM, Limbert C, Phelan H, Virmani A, Wood J, Hofer SE. ISPAD Clinical Practice Consensus Guidelines 2018: Sick day management in children and adolescents with diabetes. Pediatr Diabetes 2018;19 Suppl 27:193-204.|