With inputs from Dr Monica Vasudev

1048: New guidance from the UK National Diabetes COVID-19 Response Group [August 2 in Diabetic Medicine]

1. Address the triple insult of dexamethasone-induced impaired glucose metabolism, COVID-19-induced insulin resistance, and COVID-19 impaired insulin production.
2. Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial revealed that dexamethasone led to reduction in deaths in patients with COVID-19 on ventilators or receiving oxygen therapy. The dose used in the trial was 6 mg daily for 10 days, which is 5 to 6 times greater than the therapeutic glucocorticoid replacement dose.
3. High glucocorticoid doses can result in exacerbation of hyperglycemia in those with established diabetes, can unmask undiagnosed diabetes, cause hyperglycemia or new-onset diabetes, and can also lead to hyperglycemic hyperosmolar state (HHS).
4. The guidance recommends a target glucose of 108-180 mg/dL and further states that up to 216 mg/dL is acceptable.
5. It recommends the use of once- or twice-daily NPH insulin for patients with glucose above 216, in certain cases with the addition of a long-acting analog.
6. Patients already taking premixed insulin formulations can continue, while increasing the dose by 20% to 40%.
7. Considering the risk of hypoglycemia associated with those formulations, many experts say that they would switch those patients to NPH during the time theyre being given dexamethasone. [Medscape Excerpts]

Comments

1. Steroid induced high sugar is often post meals.
2. Give repaglinide 1 mg or 2 mg sublingual before meals.
3. Add 0.3 units insulin per kg in divided doses.
4. In high-risk cases steroids may have to be started on day 1 itself so adjust dose accordingly.
5. In post COVID illness, steroids may have to continue for weeks together like in any immunological illness.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA