Management of diabetes in patients with COVID-19

We read with great interest the Personal View by Stefan Bornstein and colleagues¹ on the management of diabetes in patients with COVID-19. During these unprecedented times, more guidance is required to care for this high-risk population. The authors recommend intensification of glucose control to prevent COVID-19, suggesting an HbA_1c of less than 53 mmol/mol (<7%) and plasma glucose concentration of 4–8 mmol/L (72–144 mg/dL) for most patients, and 5–8 mmol/L (90–144 mg/dL) for frail patients. These glycaemic goals for the older population are much tighter than suggested in most guidelines. Older patients with diabetes are a heterogeneous population with varying levels of complexity, multimorbidity, geriatric syndromes, functional abilities, and life expectancy. Some patients rely on caregivers, whereas others live in assisted living facilities or long-term care facilities. Consideration of these factors when deciding on glycaemic goals is even more critical at this time because older adults are in isolation and support from family, caregivers, or nurses might be limited. Previous studies have shown that intensive control (HbA_1c <7%) in older adults with diabetes did not lead to a significant reduction in cardiovascular events, and conversely, increased the risk of hypoglycaemia and death.2, 3 In a study of older adults aged 75 years or older with type 2 diabetes and high complexity or comorbidities,⁴ those who were treated with intensive glycaemic control (HbA_1c <7%) had double the risk of severe hypoglycaemia compared with those given standard treatment. Therefore, changes made to diabetes treatment plans must minimise the risk of hypoglycaemia, because it can lead to grave consequences such as increased falls, fractures, hospitalisations, cerebrovascular and cardiovascular events, cognitive dysfunction, and even death.⁵ Although the practical recommendations provided by Bornstein and colleagues¹ serve as an important guide for clinicians treating patients with diabetes, a different approach is needed for older adults with functional and cognitive decline, as well as those living in long-term care facilities. This approach should include avoiding any intensification or changes in medications that could lead to hypoglycaemia and increased treatment burden. In addition, for many of these patients, self-care activities such as diet and exercise routines might have been interrupted. Providing reassurance to patients can be helpful to reduce feelings of stress or guilt if their routine has not been maintained. As the pandemic unfolds and life normalises to some extent, diabetes management and glycaemic goals can be revisited.