COVID-19 and Diabetes Outcomes: Rationale for and Updates from the CORONADO Study

Fever as a Predictor of COVID-19 Outcomes in Hospitalized Patients

INTRODUCTION

With the advent of the COVID-19 pandemic, numerous questions have arisen regarding the screening, diagnosis, treatment, and prognosis of infected patients. Among these, screening infected patients through body temperature measurement has proven ineffective. However, doubts persist regarding the role of fever as a prognostic factor in the disease.

OBJECTIVE

To assess the prevalence of fever and its relevance as a marker of mortality in COVID-19.

METHODOLOGY

This prospective and longitudinal cohort study was conducted between April 2020 and December 2021 and analyzed 1400 COVID-19 patients systematically admitted to the emergency department of a reference hospital during the period from April 2020 to December 2021, in the city of Curitiba, Brazil. [LG1] The study evaluated [LG2] the presence of fever (body temperature above 37,7ºC) upon admission and/or during hospitalization, patient profiles, and outcomes (in-hospital death, discharge, admission at the intensive care unit, need of mechanical ventilation).

RESULTS

Fever was present in 128 participants (9.1%), with a higher prevalence in males (71%) and obese individuals (42.9%). Among the febrile patients, 39 required intubation (30.4%), with two intubated upon admission (1.5%), 104 were discharged (81.2%), and 24 deceased (18.7%). Fever was not associated with a higher mortality rate.

CONCLUSION

Fever showed low prevalence, is more common in males and obese individuals, and is not related to worse clinical outcomes.

"Does Physical Exercise Promote Health Benefits for Diabetic Patients during the COVID-19 Pandemic?": A Systematic Review

Patients affected by COVID-19 are prone to facing disorders in multiple systems and organs, which can lead to deleterious diseases; in addition, people with pre-existing diseases may be more prone to the worst outcomes, and the most vulnerable are patients with type 1 and type 2 diabetes mellitus. The aim of this systematic review was to evaluate the effects of physical activity and/or physical exercise prescribed to individuals with diabetes on the maintenance of plasma glucose and glycated hemoglobin during the COVID-19 pandemic. Studies were found by searching PubMed, SCOPUS, Embase, Web of Science, SciELO, LILACS, SportDiscus, Bireme/BVS and Google Scholar databases. The inclusion criteria were articles that addressed only patients with type 1 or type 2 diabetes (T1D and T2D) who had evaluated the level of physical activity or physical exercise and described the effects on plasma glucose and/or glycated hemoglobin in cross-sectional, retrospective, and observational studies, meeting the main criteria established by GRADE. The PICO and GRADE strategies were used to select and assess the methodological quality of studies. Two reviewers searched and selected the articles in databases independently and blindly, during which oppositions and disagreements about the inclusion of articles were discussed and resolved by a third reviewer. Evidence corroborates that levels of physical activity were reduced due to the lockdown, leading to increased body weight and worse glycemic control. On the other hand, individuals with diabetes mellitus (DM) (T1D and T2D) who maintained and/or increased levels of physical activity or physical exercise showed reduced plasma glucose and glycated hemoglobin (HbA1c) levels. Adequate levels of physical exercise and physical activity are beneficial for glucose and HbA1c control in diabetic patients (type 1 or type 2). In addition, maintaining adequate levels of physical activity can contribute to reducing health problems when these patients are infected with COVID-19.

Investigating the impact of metformin on severity of COVID-19 in patients with Type 2 diabetes mellitus: Focusing on laboratory findings

BACKGROUND

In the terrifying pandemic caused by SARS-CoV-2, diabetic patients exhibiting more severe outcomes and mortality rate is high among them. Based on recent studies, metformin as the most prescribed drug for T2DM treatment may improve severe outcomes in diabetic patients infected with SARS-CoV-2. On the other hand, abnormal laboratory findings can help to differentiate between the severe and non-severe form of COVID-19. According to the mentioned issues, the effect of metformin on severity of COVID-19 was examined in T2DM patients with SARS-CoV-2 infection.

METHODS

The study included 187 individuals diagnosed with COVID-19, 104 patients were diabetic and divided into two groups according to their anti-diabetic drugs: patients who were treated only with metformin and patients who were treated with other anti-diabetic drugs. The other participants were non-diabetic and diagnosed with COVID-19. Biochemical parameters were measured by routine laboratory methods before, during and after SARS-CoV-2 infection.

RESULTS

During infection, FBS, creatinine, ALT, AST, Ferritin and LDH were significantly lower in metformin users than non-users (p-value: .02, .01, .03, .04, .0009 and .01, respectively). Also, after recovery, there were statistically significant differences between metformin users and non-users with respect to most of the study parameters, except FBS, BUN and ALP (p-value: .51, .28 and .35, respectively).

CONCLUSION

Our result suggested that metformin might be associated with better outcomes in diabetic patients infected with SARS-CoV-2.

Current management of diabetes patients with COVID-19

INTRODUCTION

Diabetes mellitus (DM) and the 2019 coronavirus (COVID-19) appear to interact in both directions. There is mounting proof that patients with DM have a worse COVID-19 prognosis than those without it. Pharmacotherapy is also known to affect in view of the possible interplay between drugs and the pathophysiology of the above conditions in a given patient.

AREAS COVERED

In this review, we discuss the pathogenesis of COVID-19 and its connections with diabetes mellitus. We also analyze the treatment modalities for COVID-19 and diabetes patients. The possible mechanisms of the different medications and their management limitations are also systematically reviewed.

EXPERT OPINION

COVID-19 management as well as its knowledge base is changing constantly. The Pharmacotherapy and the choice of drugs also need to be specifically considered in view of the concomitant presence of these conditions in a patient. Anti-diabetic agents must be carefully evaluated in diabetic patients in view of the disease's severity, blood glucose level, appropriate treatment, and other components that could aggravate adverse events. A methodical technique is anticipated to enable the safe and rational use of drug therapy in COVID-19-positive diabetic patients to take.

Current management of diabetes patients with COVID-19

INTRODUCTION

Diabetes mellitus (DM) and the 2019 coronavirus (COVID-19) appear to interact in both directions. There is mounting proof that patients with DM have a worse COVID-19 prognosis than those without it. Pharmacotherapy is also known to affect in view of the possible interplay between drugs and the pathophysiology of the above conditions in a given patient.

AREAS COVERED

In this review, we discuss the pathogenesis of COVID-19 and its connections with diabetes mellitus. We also analyze the treatment modalities for COVID-19 and diabetes patients. The possible mechanisms of the different medications and their management limitations are also systematically reviewed.

EXPERT OPINION

COVID-19 management as well as its knowledge base is changing constantly. The Pharmacotherapy and the choice of drugs also need to be specifically considered in view of the concomitant presence of these conditions in a patient. Anti-diabetic agents must be carefully evaluated in diabetic patients in view of the disease's severity, blood glucose level, appropriate treatment, and other components that could aggravate adverse events. A methodical technique is anticipated to enable the safe and rational use of drug therapy in COVID-19-positive diabetic patients to take.

[The impact of carbohydrate metabolism disorders on the early and long-term clinical outcomes of patients with COVID-19 according to the AKTIV and AKTIV 2 registries]

BACKGROUND

Numerous studies indicate a high incidence of various disorders of carbohydrate metabolism against the new coronavirus infection. These disorders aggravate the course of infection and increase mortality. Thereby, analysis of risk factors for unfavorable outcomes and assessment of the long-term consequences of COVID-19 in patients with impaired carbohydrate metabolism is of great importance.

AIM

To investigate the association between carbohydrate metabolism disorders in COVID-19 patients and mortality, course of infection, long-term consequences, as well as to identify risk factors for an unfavorable disease course.

MATERIALS AND METHODS

A retrospective analysis of data from the combined multicenter non-interventional real-world AKTIV and AKTIV 2 registries was performed. The sample included 9290 patients who had COVID-19 with varying severity from June 29, 2020, to November 29, 2020 (AKTIV) and from October 01, 2020, to March 30, 2021 (AKTIV 2). The patients were divided into 3 groups: Group 1 - patients with intact carbohydrate metabolism, n=6606; Group 2 - patients with newly diagnosed hyperglycemia (NDH), n=1073; Group 3 - patients with a history of type 2 diabetes mellitus (DM2), n=1611. The groups were assessed for clinical and laboratory parameters, comorbidities, mortality, carbohydrate metabolic status, and well-being during the infection and at 12 months.

RESULTS

The prevalence of carbohydrate metabolism disorders (CMD) was 28,9%, with DM2 patients accounting for 17,3% and patients with newly diagnosed hyperglycemia (NDH) for 11,6%. The mortality rate of patients with hyperglycemia of any origin was 10.6%, which was significantly higher compared to patients without hyperglycemia (3,9%). The probability of lethal outcome increased 2,48-fold in the group of patients with DM2 and 2,04-fold in the group of patients with NDH. At the same time, the probability of a lethal outcome decreased 2,94-fold in patients without CMD. At 12 months, patients with CMD showed a significantly higher frequency and longer persistence of complaints. This trend was more pronounced in patients with DM2 than in those with NDH. Only 1,7% of patients from the NDH group had type 2 diabetes and were receiving oral hypoglycemic medications one year after the infection. A prognostic model was developed to determine the risk of lethal outcome. The model included such known predictors as concomitant ischemic heart disease, history of myocardial infarction or stroke, blood glucose level, and age.

CONCLUSION

Carbohydrate metabolism disorders aggravate the course of COVID-19 and increase mortality. One year after infection, patients with DM2 and NDH were more likely to have symptoms typical for post-COVID syndrome, and NDH resolved in most cases after the infection.

Association of Obesity and Diabetes with SARS-Cov-2 Infection and Symptoms in the COVID-19 Community Research Partnership

OBJECTIVE

Obesity and diabetes are established risk factors for severe SARS-CoV-2 outcomes, but less is known about their impact on susceptibility to COVID-19 infection and general symptom severity. We hypothesized that those with obesity or diabetes would be more likely to self-report a positive SARS-CoV-2 test, and among those with a positive test, have greater symptom severity and duration.

METHODS

Among 44,430 COVID-19 Community Research Partnership participants, we evaluated the association of self-reported and electronic health record obesity and diabetes with a self-reported positive COVID-19 test at any time. Among the 2,663 participants with a self-reported positive COVID-19 test during the study, we evaluated the association of obesity and diabetes with self-report of symptom severity, duration, and hospitalization. Logistic regression models were adjusted for age, sex, race/ethnicity, socioeconomic status, and healthcare worker status.

RESULTS

We found a positive graded association between Body Mass Index (BMI) category and positive COVID-19 test (Overweight OR = 1.14 [1.05-1.25]; Obesity I OR = 1.29 [1.17-2.42]; Obesity II OR = 1.34 [1.19-1.50]; Obesity III OR = 1.53 [1.35-1.73]), and a similar but weaker association with COVID-19 symptoms and severity among those with a positive test. Diabetes was associated with COVID-19 infection but not symptoms after adjustment, with some evidence of an interaction between obesity and diabetes.

CONCLUSIONS

While the limitations of this health system convenience sample include generalizability and selection around test-seeking, the strong graded association of BMI and diabetes with self-reported COVID-19 infection suggests that obesity and diabetes may play a role in risk for symptomatic SARS-CoV-2 beyond co-occurrence with socioeconomic factors.

Analysis of risk factors for COVID-19-related fatal outcome in 337991 patients with type 1 and type 2 diabetes mellitus in 2020–2022 years: Russian nationwide retrospective study

BACKGROUND: The coronavirus pandemic has had an extremely negative impact on the patients with diabetes mellitus (DM both in terms of a more severe course of COVID -19 and an increased risk of death.

AIM: Analysis of risk factors for death due to COVID -19 in patients with DM type 1 and type 2 (DM1 and DM2).

MATERIALS AND METHODS: Retrospective analysis of the database of the national diabetes register (NDR), which included DM patients with COVID-19 and reported virus infection outcome (recovery/or death) in 15 712 DM1 and 322 279 DM2 patients during a 2-year follow-up period (01/02/2020 to 03/04/2022) (discharge date)).

RESULTS: Case fatality rate in patients with DM, who underwent COVID -19 was 17.1% (DM1–8.8%; DM2–17.5%). As a result of multivariate regression analysis of seven significant factors in DM1 and thirteen in DM2 (evaluated by univariate anlisys), a number of the most important predictors of risk for fatal outcome were identified: in DM1 these were age ≥65 years (OR =4.01, 95% CI: 1.42–11.36), presence of arterial hypertension (AH) (OR =2.72, 95% CI: 1.03 -7.16) and diabetic foot syndrome (DFS) (OR = 7.22, 95% CI: 1.98–26.29); for T2DM: age ≥ 65 years (OR =2.53, 95% CI: 1.96–3.27), male (OR =1.51, 95% CI: 1.23–1.84), duration DM ≥10 years (OR =2.01, 95% CI: 1.61–2.51), BMI ≥ 30 kg/m2 (OR =1.26, 95% CI: 1.02–1.55), ASCVD/CKD (OR =1.49, 95% CI: 1.01–2.04), history of diabetic coma (OR =12.97, 95% CI: 1.89–88.99) and presence of disability ( OR =1.40, 95% CI: 1.14–1.73). In T2DM, the type of antidiabetic therapy (ADT) prior to COVID -19 (last visit before the development of infection) had a significant impact: Insulin therapy (OR = 1.64, 95% CI: 1.30–2.07), sulfonylureas (SU) (OR =1.51, 95% CI: 1.23–1.84)); dipeptidyl peptidase-4 inhibitor (iDPP-4) therapy (OR =0.57, 95% CI: 0.39–0.83) and sodium-glucose cotransporter-2 inhibitor (iSGLT2) therapy (OR =0.64, 95% CI: 0.46–0.88). Vaccination was the most important protective factor in both types of DM: DM1 OR =0.19, 95% CI: 0.06–0.59; SD2 OR =0.20, 95% CI: 0.16–0.26.

CONCLUSION: The common risk factor for fatal outcome in both DM1 and DM2 was age ≥65 years; in DM1 — history of hypertension and DFS, in DM2 — male sex, diabetes duration ≥10 years, BMI ≥30 kg/m2, history of ASCVD/CKD and diabetic coma, disability. In T2DM, significant differences in risk were observed depending on the type of ADT: insulin and SU therapy were factors that increased the risk of death, whereas therapy with iDPP-4 and iSGLT2 reduced the risk of death. Vaccination reduced the risk of death in DM1 and DM2 by 5.2 and 5-fold, respectively.

Stress Hyperglycemia Ratio as a Prognostic Marker in Diabetic Patients Hospitalized with COVID-19

Evidence is conflicting about the diabetes characteristics associated with worse outcome among hospitalized COVID-19 patients. We aimed to assess the role of stress hyperglycemia ratio (SHR) as a prognostic marker among them. In our retrospective cohort study, patients were stratified according to SHR, admission glucose, and glycated hemoglobin tertiles. The primary outcome was a composite endpoint of invasive mechanical ventilation, intensive care unit admission, and in-hospital mortality. The study included 395 patients with a mean age of 59 years, and 50.1% were males. Patients in the third tertile of SHR developed more primary events, and the difference was significant compared to the first tertile (p = 0.038) and close to significance compared to the second tertile (p = 0.054). There was no significant difference in the outcomes across admission glucose and glycated hemoglobin tertiles. A higher SHR tertile was an independent risk factor for the primary outcome (OR, 1.364; 95% CI: 1.014–1.836; p = 0.040) after adjustment for other covariables. In hospitalized COVID-19 diabetic patients, SHR third tertile was significantly associated with worse outcome and death. SHR can be a better prognostic marker compared to admission glucose and glycated hemoglobin. A higher SHR was an independent risk factor for worse outcome and in-hospital mortality.

Diabetes and COVID-19: Short- and Long-Term Consequences

When the corona pandemic commenced more than two years ago, it was quickly recognized that people with metabolic diseases show an augmented risk of severe COVID-19 and an increased mortality compared to people without these comorbidities. Furthermore, an infection with SARS-CoV-2 has been shown to lead to an aggravation of metabolic diseases and in single cases to new-onset metabolic disorders. In addition to the increased risk for people with diabetes in the acute phase of COVID-19, this patient group also seems to be more often affected by long-COVID and to experience more long-term consequences than people without diabetes. The mechanisms behind these discrepancies between people with and without diabetes in relation to COVID-19 are not completely understood yet and will require further research and follow-up studies during the following years. In the current review, we discuss why patients with diabetes have this higher risk of developing severe COVID-19 symptoms not only in the acute phase of the disease but also in relation to long-COVID, vaccine breakthrough infections and re-infections. Furthermore, we discuss the effects of lockdown on glycemic control.