The parallel pandemic of diabetes and COVID-19 unveils a host of complications when combined. It is indeed already recognized that diabetes has been known to worsen the prognosis in earlier viral infections. However, this time around, the severity seems to be increasing considering the global prevalence of diabetes and rates of infection of SARS-CoV-2. Consequently, due to lockdown and isolation, it was observed that almost 60%-70% of patients in India have uncontrolled glycemia and there is a steep rise in diabetes-related complications as well. During the lockdown, disorganized lifestyle such as lack of physical activity, stress and improper eating habits have led to uncontrolled hyperglycaemia, eventually leading to weight gain and sharp fluctuations in blood glucose levels in diabetes patients.

Even though the significance of good glycemic control in all patients of diabetes, at all times, cannot be emphasized more, special importance to strict glycemic control has been a priority in diabetes management in these COVID times. The use of metformin significantly accelerates glucose clearance and reduces hyperglycaemia. Studies have reported the beneficial outcomes of high dose metformin in all the parameters of glycemic pentad including maximum HbA1c reduction, maximum FPG reduction, least PPG elevation, better mean 24-hour glucose control and much-reduced risk of hypoglycaemia. A recent diabetes management algorithm suggests that in COVID-19 patients with hyperglycaemia (previously diagnosed or undiagnosed), therapy should be escalated if needed. Metformin should be escalated if there are no other contraindications or abdominal distress in the patient. Studies have shown that metformin dose escalation is as significant as adding other oral hypoglycemic agents in patients who fail to achieve glycemic control with initial metformin monotherapy. Experts have also recommended that metformin should be continued in patients with mild and moderate cases of COVID-19 as it is associated with reduced mortality in COVID 19.

Given the pleiotropic benefits of metformin, (such as anti-inflammatory, antioxidant, benefits in lung disease, the effect on age-related pathways, growth inhibitory and neoplastic effects, improvement in endothelial dysfunction)and its role in fast glucose control, it can be a real game-changer in the management of COVID-19 patients.

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