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With inputs from Dr Monica Vasudev
1048: New guidance from the UK National Diabetes COVID-19 Response Group [August 2 in Diabetic Medicine]
- Address the triple insult of dexamethasone-induced impaired glucose metabolism, COVID-19-induced insulin resistance, and COVID-19 impaired insulin production.
- 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.
- 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).
- The guidance recommends a target glucose of 108-180 mg/dL and further states that up to 216 mg/dL is acceptable.
- 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.
- Patients already taking premixed insulin formulations can continue, while increasing the dose by 20% to 40%.
- 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]
- Steroid induced high sugar is often post meals.
- Give repaglinide 1 mg or 2 mg sublingual before meals.
- Add 0.3 units insulin per kg in divided doses.
- In high-risk cases steroids may have to be started on day 1 itself so adjust dose accordingly.
- 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