Table 1.

Summary of recommendations regarding COVID-19 in patients with diabetes and/or cardiovascular disease.

S. No	Stage of COVID-19 infection	Interventions/indications
1	Prevention of infection and containing pandemic	1. Wash your hands frequently with soap and water for 20 s or clean with alcohol-based hand rub 2. Maintain social distancing (2 meters or 6 feet) 3. Cough or sneeze into tissue or elbow 4. Avoid touching your face 5. Sanitize surfaces frequently
2	Symptomatic stage	1. If the patient is feeling unwell, he/she should stay at home 2. If the patient has fever, cough and/or difficulty breathing, seek medical attention and call in advance 3. Follow the directions of your local health authority
3	Controlling diabetes during illness	General sick day diabetes management principles (modified from ISPAD guidelines): 1. More frequent blood glucose and ketone (blood or urine) monitoring 2. Aim for a blood glucose level between 4 and 10 mmol/L (70–180 mg/dL) and blood ketones below 0.6 mmol/L when the child is ill 3. NEVER STOP INSULIN: If there is FEVER, insulin needs are usually higher 4. Monitor and maintain hydration with adequate salt and water balance 5. Treat underlying illness and symptoms (fever)
4.	URGENT specialist advice/referral to emergency	1. Fever or vomiting persists and/or weight loss continues, suggesting worsening dehydration and potential circulatory compromise 2. Fruity breath odor (acetone) persists or worsens / blood ketones remain elevated >1.5 mmol/L or urine ketones remain large despite extra insulin and hydration 3. The patient is becoming exhausted, confused, hyperventilating (Kussmaul breathing), or has severe abdominal pain 4. Identify COVID-19 patients who are at high-risk of venous thromboembolism (VTE), including those with prolonged immobility, overlapping cardiovascular disease (CVD) risk factors (adiposity, age and smoking) or with high estrogen levels (including those on exogenous hormone therapy). Consider initiating appropriate prophylaxis. If at higher risk of bleeding due to anticoagulation, adjust anticoagulation dose and duration as well as use of mechanical compression 5. Patients with body mass index (BMI) of 30 kg/m2 or higher should be considered at high risk given the association of these patients with significantly higher mortality after COVID-19 infection. These patients need close monitoring over teleconsultation * 6. Patients who are at increased risk of QTc interval prolongation, life-threatening cardiac arrhythmic events and/or sudden cardiac death (e.g., COVID-19 positive patients with: (a) history of diabetes and/or CVD, and/or (b) those on post-exposure prophylaxis or treatment of COVID-19 using “off-label” drugs such as hydroxychloroquine, azithromycin and lopinavir/ritonavir)

Source:Prepared and adapted by the authors from the ISPAD guidelines.

ISPAD: International Society for Pediatric and Adolescent Diabetes.

^*Based on the analysis of Intensive Care National Audit & Research Centre (ICNARC) United Kingdom data set (analyzed on April 4, 2020).

^↑Recommendations of the CVD and diabetes subcommittee of the COVID-19 Pandemic Health System REsilience PROGRAM (REPROGRAM) consortium.