| Diabetes mellitus |
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a.
Patients with preexisting diabetes mellitus should be more vigilant about optimum glycemic control in the post-COVID period.
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b.
In patients without preexisting diabetes:
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i.
Routine evaluation of glycemic status in patients with COVID-19 without documented in-hospital hyperglycemia or new-onset diabetes mellitus is not recommended. Patients with COVID-19 admitted to the ICU and those aged <70 years are at high risk of new-onset diabetes post-COVID and, hence may be screened for new-onset diabetes at 3 months after discharge with a fasting plasma glucose or 2-hour plasma glucose during oral glucose tolerance test or HbA1C as per the ADA Standards of Medical Care in Diabetes. 22
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ii.
Patients with COVID-19 with documented in-hospital hyperglycemia (including steroid-induced hyperglycemia) but normoglycemia and off all antidiabetic drugs at the time of discharge should be reevaluated at 3 months after discharge with a fasting plasma glucose or 2-hour plasma glucose during oral glucose tolerance test or HbA1C as per the ADA Standards of Medical Care in Diabetes. 22
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iii.
Patients with COVID-19 with documented in-hospital hyperglycemia (including steroid-induced hyperglycemia) and discharged on antidiabetic medications should maintain glycemic control based on the standard of care. The dose and number of antihyperglycemic medications should be adjusted as per the glycemic profile. Antidiabetic medications may need to be stopped based on the blood glucose profile. It may be possible to discontinue antihyperglycemic medications in those with confirmed stress-induced hyperglycemia, that is, an HbA1C level of <6.5% in the presence of hyperglycemia at the time of discharge.
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c.
Patients with COVID-19 with diabetes mellitus/hyperglycemia are at high risk of mucormycosis even after recovery from COVID-19, and the caregivers need to be vigilant about the same.
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d.
Screening for other diabetes-related complications should be undertaken as per standard of care.
|
| Thyroid |
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a.
Patients with COVID-19 with biochemically documented euthyroid sick syndrome during the acute phase of the disease may undergo a thyroid function test performed at 6 weeks after discharge.
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b.
Patients with COVID-19 with biochemically documented subclinical hypothyroidism during the acute phase of the disease should undergo a thyroid function test 3 months after discharge. An anti-TPO antibody assay should be performed if not found to be positive during the acute phase of COVID-19.
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c.
Patients with COVID-19 with biochemically documented overt hypothyroidism during the acute phase of the disease should undergo a thyroid function test performed at 6 weeks after discharge while on levothyroxine supplementation. An anti-TPO antibody assay should be performed if not found to be positive during the acute phase of COVID-19.
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d.
Patients with COVID-19 with biochemically documented hyperthyroidism/subclinical hyperthyroidism/subacute thyroiditis during the acute phase of the disease should undergo a thyroid function test performed at 6 weeks after discharge. An anti-TPO antibody assay should be performed if not found to be positive during the acute phase of COVID-19. Even if the thyroid function at 6 weeks is normal, a repeat test should be performed at 12 weeks to rule out the possibility of postthyroiditis hypothyroidism.
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e.
Patients with COVID-19 with normal thyroid function assessed during the acute phase of the disease do not need a routine reestimation of thyroid function on follow-up.
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f.
Patients with COVID-19 in whom thyroid function was not estimated during the acute phase of the disease do not require a routine assessment of thyroid function on follow-up, even in those complaining of persistent fatigue.
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g.
Patients who have recovered from COVID-19 complaining of neck pain, weight loss, resurgence of fever, and/or palpitations should be suspected of having subacute thyroiditis. A thyroid function test should be immediately performed, and if suggestive of thyrotoxicosis, a radionuclide thyroid uptake scan using technetium-99 m may be ordered (if facilities are available). A combination of high erythrocyte sedimentation rate (and/or C-reactive protein levels) and poor radionuclide uptake by the thyroid gland is diagnostic of subacute thyroiditis. A thyroid-stimulating immunoglobulin assay may be ordered when Graves disease is suspected.
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| Adrenals |
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a.
We do not recommend the routine estimation of serum cortisol/ACTH in post-COVID patients.
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b.
Since patients with COVID-19 treated with dexamethasone as per the RECOVERY trial (6 mg once a day for a maximum of 10 days) do not have impaired adrenal function, they do not require a routine evaluation of adrenal function in the post-COVID setting.
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c.
Patients with COVID-19 who have received steroids during the acute phase of the disease for <3 weeks are unlikely to have clinically significant HPA axis suppression and, hence, do not require the evaluation of their HPA function.
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d.
Suppression of the HPA axis is inevitable in patients taking the equivalent of 15 mg/day or more of prednisolone for ≥3 weeks. Hence, the evaluation of the HPA axis may be performed after tapering and stopping glucocorticoids.
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e.
Morning serum cortisol/ACTH levels may, however, be estimated in post-COVID patients with surrogate evidence of AI, that is, recent onset anorexia, involuntary weight loss, diarrhea, hyponatremia and/or hyperkalemia, and/or eosinophilia.
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f.
Patients with COVID-19 with biochemically documented AI during the acute phase of the disease should undergo a morning serum cortisol/ACTH test estimated with/without Synacthen stimulation test at 12 weeks after discharge, withholding hydrocortisone 24 h prior to the test.
-
g.
Any documentation of central AI (in the absence of a prior history of glucocorticoid intake) should prompt the evaluation for other anterior pituitary hormone deficiencies.
|
| Pituitary |
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a.
Patients with COVID-19 complaining of new-onset headache and visual disturbance post-recovery should be suspected of having pituitary apoplexy, and a noncontrast computed tomography of the head should be performed at the earliest. The possibility of pituitary apoplexy should be kept higher on the cards, especially in those already known to have an underlying pituitary adenoma, pregnant women, and those on antiplatelet medications.
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b.
Patients with COVID-19 diagnosed with pituitary apoplexy in the acute phase of the disease and not found to have any anterior pituitary hormone deficiency should be reevaluated at 6 weeks for incident hormone deficiencies.
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c.
Patients with COVID-19 diagnosed with pituitary apoplexy in the acute phase of the disease and found to have 1 or more anterior pituitary hormone deficiencies and supplemented with the respective hormones should be reevaluated at 6 weeks for other incident hormone deficiencies.
|
| Gonads |
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a.
Men with COVID-19 with biochemically documented hypogonadism (either primary or secondary) during the acute phase of the disease should undergo serum total testosterone, LH, and FSH tests performed at 3 months after discharge.
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b.
Men with COVID-19 with normal gonadal function documented during the acute phase of the disease do not require a routine reevaluation of gonadal hormones on follow-up.
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c.
Men with COVID-19 in whom the gonadal function was not estimated during the acute phase of the disease do not require a routine assessment of gonadal hormones on follow-up.
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d.
Men who have recovered from COVID-19 and complaining of new-onset erectile dysfunction and/or low/loss of libido should undergo serum total testosterone, LH, and FSH tests performed irrespective of the gonadal status during the acute phase of the disease. A psychiatry opinion should be sought to exclude psychogenic erectile dysfunction in such men with normal gonadal function.
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e.
On follow-up, men found to have hypogonadism (low serum total testosterone level) with low/normal LH/FSH levels after recovery should be evaluated for other anterior pituitary hormone deficiencies. In addition, the serum prolactin level should also be estimated.
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f.
On follow-up, in men found to have hypogonadism (low serum total testosterone level) with elevated LH/FSH levels after recovery, a possibility of a primary testicular failure should be kept in mind.
-
g.
In either scenario, a semen analysis may be performed for men of reproductive age if they wish to father children.
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h.
Routine semen analysis in men of the reproductive age group desirous of a future child is not recommended.
-
i.
Hitherto, there is no robust evidence to recommend a routine evaluation of gonadal function in women of childbearing age who have recovered from COVID-19.
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| Bone and mineral metabolism |
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a.
We do not recommend the routine estimation of serum calcium in post-COVID patients.
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b.
Patients with COVID-19 with symptomatic hypocalcemia during the acute stage of the disease should undergo a repeat estimation of serum calcium at 2 weeks after discharge.
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c.
The 25-hydroxyvitamin D levels may be estimated in post-COVID patients, and vitamin D be supplemented accordingly.
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| COVID-19 vaccination and endocrine systems |
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a.
Subjects complaining of involuntary weight loss, palpitations, tremors, and/or neck pain after vaccination with vector-based or mRNA-based SARS-CoV-2 vaccines should be suspected of having thyrotoxicosis, and a thyroid function test should be performed.
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