Transcription:
COVID-19 and Diabetes: Key Recommendations for Endocrinologists

Melanie Cole: This is the Northwestern Medicine Podcast on COVID-19 dated April 21st, 2020. Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. Today we're discussing COVID-19 and diabetes care. Joining me is Dr. Grazia Aleppo. She's a Professor of Medicine and the Director of the Northwestern Medicine Diabetes Training and Education Program. Dr. Aleppo, it's such a pleasure to have you join us again. You were in Italy, and Spain for a conference in late February and saw the COVID-19 situation. Escalate there. Please tell us about your experience. I find this so interesting and can't wait to hear this answer.

Dr. Aleppo: I was there in Spain in mid-February for a conference, for a medical conference on diabetes and technology. And when I left, I started seeing in Spain, people with masks just about everywhere, even though there were no cases. Then we knew and hand sanitizer given to us at the conference from every possible booth. But then I went to visit my family in Southern Italy and within three or four days, the outbreak started in Northern Italy and they closed all the schools and it felt really something serious was happening. In fact, I came back just in time to the States. I came back the day after the President announced the travel ban, so I was a bit anxious on my flight that I could get back. But I did. And so I thought, okay this had not touched us in this States then, but I felt that it was something we should start really being concerned about.

Host: So since you felt that way, how did it impact your decision making plan for your patients when you got back?

Dr. Aleppo: So I thought, okay. Our patients’ population is mainly patients with diabetes, at least from my practice. And our patients have a lot of comorbidities. They're also elderly. Many of them they also have history of transplant. So they're immunocompromised patients. I felt that we should start offering patients, first of all, working from home for our patients. And so we started receiving a lot of phone calls from patients who were obviously anxious. And so we offered letters to them, instructions. We made all sorts of pre written, we call the smart sets of smart phrases from our medical records. So we were prepared to talk with our patient and say, this is what the symptoms are, this is what the CDC says you should do, and if you can work from home, we'll help you with letters to your employer, which we did. Then we said, okay, weeks come by and things are getting more serious, we thought, okay, we need to allow our patients to stay home and we need to start implementing a virtual clinic.

So we got together with our clinical practice director, Dr. Alison Har, and we met with all our nursing staff and our patient liaison schedulers. And I must say this was a phenomenal, phenomenal team work really. And we made a protocol for how to modify our visits from in person to over the phone to eVisits. And we made a protocol to recognize which patient had accepted the visits. We made notes on a scheduling system that is Epic for medical records. And we also develop some system to educate the patient how to implement uploading of the diabetes devices and how to be able to handle the visit over the phone. Not only that, we then set up a system to really help our patients with refills to explain them what sick days were and also how to try to get medication over the 90 day supply.

Host: That is so comprehensive. I'm so glad that you did that. So tell us a little bit about how the virus damages the lungs and the specific effect on those with diabetes that as you say, have many other comorbid conditions.

Dr. Aleppo: Yeah. Before you even go to that portion. More importantly, we actually may some instructions for our patients because you know, it's so easy to say, let's do a visit over the phone and what do you do with it if you cannot touch the patient. So we told them how to handle the visits and we developed some illustrated sort of modules to help our staff to upload their tools, to look at the insulin pump data and the continuous glucose monitoring data. And so by doing that we really enhance the effect on the visit and the patient has been very, very happy with us so far. Now going back to the virus and how it really affects our patients with diabetes, that is a bit of a convoluted situation. So first of all, diabetes is really is considered a low grade inflammatory disease that really can cause some immune system imbalance. So, and that is actually worsened by the presence of obesity. And so what happens to people with diabetes?

They have this chronic low grade ploy inflammatory state and so that facilitates some particular cytokines to be elevated. One of them is called interleukin 6, IL6 which are one of the markers of inflammation. And so people with diabetes in COVID-19 had significantly elevated levels of IL6, which can also cause or precipitate or help into causing what we call the cytokine storms, which is very, very dangerous in these patients. So the way that the virus affects patients with diabetes is that when you have high glucose level and obesity present in these patients, these two things together are putting the patient, this inflammation state, inflammatory states where they are less able to compensate with the all reserves in these cytokines that get sort of overexcited and the levels go up, can precipitate tremendously.

So this condition in these patients, even the appearance of the imaging for example, patients have pneumonia, their appearance in the CT scan generally looks worse than people without diabetes who I've also COVID, this was just reported in a publication from China, from Wuhan. And remember this, things are still becoming new and new every day, we're learning every so much more every day. And so that is what has been felt to be one of the dangers of having diabetes with high blood glucose. Because not everybody with diabetes is at increased risk of getting COVID-19. But if patients with diabetes have significantly high glucose that are uncontrolled, they have other comorbidities, they're also obese and high blood pressure and heart disease. They have the very high risk to have a very complicated course of this condition. Now, unfortunately, even younger people with diabetes had been affected by this, but again, there's such a [inaudible] is of this condition in diabetes, things we're learning every day new.

Host: Well, we certainly are. And when people with diabetes show symptoms or are actually diagnosed with COVID-19, when are you recommending admission to the hospital doctor?

Dr. Aleppo: Again, we have been given our patients who have questions generally whenever they call. We've been given to all of them understanding what COVID-19 symptoms are and how they can they need to inform us first of all. But once the patient starts developing shortness of breath, we do tell them to really go to the emergency room or to be evaluated, to be admitted. Well, I've had four patients so far, who have been diagnosed with COVID-19 and three of them have diabetes type one and one is diabetes type two. Two of them have been hospitalized, two of them have not been hospitalized. One is doing better than the others and she is home already and doing much better. But the other guy is still in the hospital. And so my concern is for this patient who have diabetes for a long time with history of transplant, this can be very concerning. So in general, we are telling our patients, if you start having a high fever and you are having cough, and shortness of breath, you must go to the hospital immediately. And then sometimes we actually have told patients that had milder symptoms. My patients who actually were diagnosed, we sent them to Northwestern Memorial hospital hotline for the COVID hotline. And they were able to get tested and they got admitted to the hospital. So I've been, I must say, very smooth for us to guide our patients towards either testing or hospitalization.

Host: So now if a patient is hospitalized, what are some of the ways that you're treating patients with COVID-19 are there any unique treatments that you're using Dr. Aleppo?

Dr. Aleppo: So this is the most interesting portion, although it's not a positive thing. We have seen all sorts of presentations of patients with diabetes, with hyperglycemia, but also patients who at home or just taking one pill, who are coming in with very, very high glucose levels and so we have to sort of be very creative how we approach these patients. This is not a sort of set up a protocol that we can use for everybody. This is becoming very individualized because some patients have a very, very high degree of insulin resistance and they require very high doses of insulin. However, some of these patients, they immediately after we give a lot of insulin because they're so elevated in their blood glucose levels, suddenly they become insulin sensitive and so the glucose levels rapidly go down. So we have to be prepared to just give a lot of insulin, forget about them, but constantly monitor this patient to say, okay, are you, is the patient glucose moving rapidly towards going down?

So to put the brakes and just got down the doses of insulin to avoid hypoglycemia. At the same time we have patients who come in with something called diabetes ketoacidosis. Again, patients who maybe weren't diagnosed with that before. In fact, we usually considered DKA, diabetes, ketoacidosis, a problem with type one patients with diabetes. But now, we're having lot of patients with type two diabetes, patients who might not be on insulin at home to begin with who are coming to us with very high glucose, with very low pH. So very acidotic. And this is something that is also very new and so we have to really adjust. In addition to that, we have been exposed to, you know, to the situation in New York. And so there there's been such a huge amount of patients in the hospital with diabetes, with high blood glucose that we tried to prepare our self to say, okay, if this situation comes towards us, how do we really limit the use of the ICU beds to the patients who really needed for the ventilator and keep the patients with diabetes, maybe even ketoacidosis outside the ICU.

And so we have developed and implemented a protocol for subcutaneous insulin administration for ketoacidosis for DKA that is generally treated with IV insulin infusion. So we're doing this to limit the, you know, the bed use in the ICU, but also to allow our nursing staff and the providers in the hospital to have limited amount of exposure. Because we're trying to decrease the number of glucose sticks that we do in this particular situation to avoid, you know, save PPE, to avoid the staff to go back and forth in the room multiple times. And so this is a work in progress, however, because things that keep changing and I am actually on call this week in the hospital and I'm seeing so many different kinds of diabetes presentation that I would not expect otherwise in the past. So a learning process for all of us.

Host: Wow. It's such great information and that was such an interesting answer. Dr. Aleppo, as we wrap up, what else would you like other healthcare providers and endocrinologists to know about COVID-19 and diabetes to take forward and manage their patients?

Dr. Aleppo: First of all, listen to your patients. They are not just panicking. They really have a condition that might take their lives and so especially if people were older with comorbidities, if a patient calls you because they concerned, listen to them, then help explain to them clearly what are the steps to be taken to either treat things at home or to go to the hospital or treating things at home. The more aggressively glucose management. Make sure the patient has fluids at home food. Because you know, right now with the grocery shopping and all the stores being closed, it could be also a problem. Make sure they have a glucose meter. They can check the glucose often, so you can try to keep them out of the hospital as much as possible. Knife they are, however, have symptoms that make you think they do have COVID-19 and then explain to them how to get to the hospital, bring even your insulin and bring your glucose meter being your list of medications. So when the patient is in the hospital, has all the things that they need to stay there with a good result, at least for what they can do. As far as the diabetes is concerned. Of course for the, the situation with the disease, there are so many unknowns. So many times this condition gets worse all of a sudden, we cannot predict the outcome, but at least help your patient be ready for a variety of things, even emotionally to get through this time of the COVID-19 as healthy as possible.

Host: Really true, and thank you so much, Dr. Aleppo for coming on again. You are a great guest as always. Thank you so much again. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians. To refer your patient or for more information on COVID-19, please visit our website at nm.org to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine Podcasts. I'm Melanie Cole.