Dr. Rahul is a consultant in Diabetology, Bombay Hospital, Mumbai. In this episode Dr. Rahul explains the key aspects related to Diabetes management during Covid-19 pandemic. We discuss about following:

  • Whether people with diabetes are more likely to get Covid-19?
  • Complications in Diabetes patient due to Covid-19.
  • Do Diabetes patient need to be concerned about DKA (diabetic ketoacidosis).
  • New-Onset Diabetes in Covid-19.
  • Warning signs that diabetes patient should be aware of.

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Transcript

Diabetes Management during COVID-19 Pandemic

A talk with Dr. Rahul Baxi.

Speaker: Mr. Vivek
[0:00]

Hello, Welcome to Dr. Talks. This is your host Vivek. Here we chat with the best doctors about diseases and conditions they treat. Our guest today is Dr. Rahul Baxi. Dr. Rahul is a consultant in Diabetology Bombay hospital, Mumbai. Welcome Dr. Rahul.

Speaker: Dr. Rahul
[0:29]

Hello, Vivek, Thank you for inviting me to Dr. Talks.

Speaker: Mr. Vivek
[0:33]

I would first request you to share more about yourself. And please do not miss to share your interest in architecture photography, because I find it very unique.

Speaker: Dr. Rahul
[0:47]

Thanks, Vivek. So, I did my MBBS from Nasik. Then I did my MD medicine from Nagpur University, Wardha. After that I worked in different hospitals like Bombay hospital, then I trained in diabetes in CMC vellore. After that I have also been trained in Singapore, I spent a good part of the last decade there actually, I spent seven years in Singapore, where I’ve trained in diabetes and I worked with Ng Teng Fong General Hospital (a member of the NUHS) Singapore. Apart from that I have a keen interest in photography. So this all started in Singapore, a few years back, I used to have some time on hand, so I used to travel a lot. And I had a particularly keen interest in architecture photography, as you said, as well as in state photography. So I was very active on Instagram now I’ve been much busier so not that much. And in fact, you would be happy to know that a couple of years back I won the Singapore instagrammer of the year award. That’s about me in brief.

Speaker: Mr. Vivek
[1:55]

I am aware you consult and advise patients to manage their Diabetes, both Type 1 and Type  2. But today I wanted to discuss diabetes management during Covid – 19 pandemic. So my first question to you would be: Are people with diabetes more likely to get Covid-19?

Speaker: Dr. Rahul
[2:18]

Okay, so as we understand in India, we have been going through this covid pandemic for the past few months. Of course, internationally also, the experience is probably over six months or so. So if you ask me, the simple answer to this question that are people with diabetes more likely to get COVID-19? The answer probably at this stage with whatever data we have is No. So diabetes patients are not more likely to get COVID-19. Of course, I mean, other factors are involved here, for example, the age of the patient, because elderly patients are more likely to be prone for infections compared to the younger ones. Then again, a very important point here to mention the level of control of diabetes at this point of time. If their glucose levels are well controlled the patient should be at lower risk. And generally speaking, younger patients, patients with controlled glucose, will not be more likely to get infected compared to those without diabetes. Of course, coming from here, I would like to mention that a patient of diabetes, if he does get infected with COVID-19, the risk of complications will be higher in those who have diabetes, and even higher in those who have diabetes, which is not well controlled, and which can affect the morbidity and mortality as well.

Speaker: Mr. Vivek
[3:34]

So it’s very clear that people having diabetes are not at higher risk in terms of getting infected with Covid-19. But you mentioned that the complications could be much more serious for such people. Can you elaborate more in terms of that? What could be the complications?

Speaker: Dr. Rahul
[3:51]

So patients who have diabetes, as I mentioned, will have higher chances of complications, especially if the diabetes control is not good, if it’s not well managed prior to getting the infection and of course, during the hospital stays as well these patients probably will have severe symptoms, and they are more likely to require oxygen support or even ventilator support. And they will, of course, have lower risk if the glucose levels are well managed over the period of time. I would like to mention here that diabetes patients are more likely to have coexisting heart diseases, kidney diseases, and other comorbidities. And of course, the presence of these additional comorbidities will worsen the progress. And the reason for this is especially because diabetes impairs the human immune response to infection, and which can lead to these complications.

Speaker: Mr. Vivek
[4:45]

Are there any statistics that show people having diabetes are at higher risks?

Speaker: Dr. Rahul
[4:50]

Okay, statistically speaking of actually the numbers are flowing in every day. This is one topic you know, COVID-19, and of course diabetes associated with that, which is changing every day. So every two, three days, we will see a new paper, we’ll see new data and a lot of new information coming in. So I was just going through a couple of studies, some of them from China, one of them was from Denmark. And they do mention that, like some of the studies have seen the number of patients in ICU having diabetes. So compared to COVID-19 patients not requiring intensive care and comparing them to requiring intensive care, there was a two fold increase, which means those who have diabetes have much higher risk of getting admitted in the intensive care unit, much higher probability of requiring ventilatory support. And of course, that will again depend on other comorbidities and diabetes control as well. So these numbers can be up to 20% to 40% as well. And speaking with my own experience, now, in the last few months, I have been seeing a lot of COVID-19 patients admitted in our hospital, I work in Bombay Hospital in Mumbai. So here we’ve been seeing a lot of COVID-19 patients, and many of them have diabetes. In fact, in a day, I see up to 30 to 40 patients of COVID-19. And who have diabetes, I manage their diabetes. And of course, they are at various levels of severity. Some of them are very stable. Some of them are recently diagnosed and not very high as we can see. And some of them of course are in the ICU  requiring ventilator support. So it can vary, and new data will keep flowing over the months, because this is changing very fast.

Speaker: Mr. Vivek
[6:29]

And as a diabetes patient, does one need to worry about diabetic ketoacidosis, which is also called a DKA.

Speaker: Dr. Rahul
[6:37]

Okay, that’s a very interesting and a very good question. DKA is very common in Type 1 diabetes, sometimes we do see diabetic ketoacidosis, which is DKA in Type 2 diabetics as well. And usually there is a precipitating factor for DKA because it’s basically a continuum of high glucose levels, dehydration, electrolyte imbalance, and usually there’s a perceiving factor which can be either some infection, which is very common, you know, usually an infection in a patient will precipitate DKA. Or sometimes if Type-1 diabetic patients stop their insulin, which can end up in diabetic ketoacidosis. So any infection and any viral infection also can increase the risk of diabetic ketoacidosis. It will be more commonly seen in Type 1 diabetes. And the challenge would be to manage the fluid balance, the electrolytes, the glucose levels. And of course, if the patient sometimes can go into infection and shock, which can lead to complications, so DKA can be a very important presentation and I have seen a few patients in the last few months as well.

Speaker: Mr. Vivek
[7:48]

Are the risks different for patients who have Type 1 and Type 2 diabetes during this COVID-19?.

Speaker: Dr. Rahul
[7:59]

Currently with the data we have, there is no reason to believe that there will be any difference in Type 1 and Type 2 in terms of getting COVID-19. So the risk remains the same. And again, as I had mentioned earlier, it would depend on the age, the comorbidities, and the glucose level glucose control. And the risk is the same as the general population. It’s not that if a patient has diabetes, they will be at more risk. If this patient gets COVID-19 infection, the risk of complications will be higher. So there is no difference in Type 1 or Type 2, in terms of getting the infection as such.

Speaker: Mr. Vivek
[8:35]

I was recently reading an article about New-Onset diabetes in COVID-19. To be frank to you, I could not understand it. Can you please explain to us what it is?

Speaker: Dr. Rahul
[8:46]

Okay, this is very interesting and very new to all of us as well. So it’s very early to say anything about this with certainty. I’ve gone through a few papers. There’s been a global patient registry started recently, which is called as COVID project, think the lead doctors are from King’s College London and around 120 hospitals around the world are contributing to this registry. So what the primary data suggests is of course, when a patient gets admitted with COVID-19, we are actually seeing the newly diagnosed diabetes patients. And the type of presentation could be Type 1 or  Type 2 and some hybrid forms as well. And of course, it’s always known that few viral infections can cause diabetes or can be associated with diabetes. Some like SARS, Coronavirus, Mumps virus, coxsackievirus enteroviruses, so these are known to be associated with diabetes, because the virus can trigger an autoimmune response, which can affect the pancreas. Now a very interesting thing about this Coronavirus, you must have read that it binds to a receptor called H2 receptor, ACA2 (Angiotensin converting enzyme 2 ) receptor.

Interestingly, these receptors are also present in pancreas, small intestines and the kidneys  and all these organs are involved in metabolic functioning. When it affects the pancreas, it may interfere with the beta cell function. And we all know that beta cells are involved in the production of insulin and glucose regulation. So that can be a very important cause. And I was also discussing with a gastroenterologist friend a while back and he mentioned that he’s been seeing some cases of pancreatitis as well in COVID-19 patients. So again, you know, there is something going on, which is affecting the pancreatic inflammation. And when the pancreas gets inflamed, the beta cells will get affected, which can affect the insulin production or the insulin function. We have seen a few newly diagnosed diabetes patients with COVID over the last few months and they’ve been managed well.

Speaker: Mr. Vivek
[10:57]

How do you suggest patients manage their diabetes during COVID-19?

Speaker: Dr. Rahul
[11:02]

I’ll answer in two parts. So the first part would be a general recommendation for all of us. They include general hygiene, regular hand washing, wearing masks, not touching the face and if we touch definitely wash your hands again and dry them out. And other routine instructions like cleaning surfaces, cleaning your mobile phones, cleaning the door handles, cleaning the television remote, very small things but very important in today’s scenario, and of course when you cough should be able to cover your mouth with a tissue. Now some places have recovered well from COVID-19 in the world so depending on that you should follow the government instructions. If it is recommended, staying at home again is very important. If it is not necessary. please do not go out at gatherings and expose yourself. So these were all general instructions for everyone. Now talking specifically about some instructions for our diabetes patients, I would say a bit, preparation is required. You know, if you have diabetes, you should plan for the future, which means in case you get unwell or you get ill, what’s your plan of action? You may need to isolate yourself. So that patient needs to have enough medications. So these things should be taken care of. Apart from that, generally speaking, diabetes patients should monitor their glucose very well. I’ve been sending messages to them, whichever patients I’ve been consulting online and in video. We discuss with patients and advise them to monitor their glucose regularly  generally and in this scenario, it becomes much more important that they should watch for low and high glucose levels. They should always stay in touch with the concerned doctors who are managing their diabetes. So if needed they can get tests done. Because traveling to the doctor’s clinic or to the hospital may not be feasible or may not be absolutely safe depending on what zone your residence and the hospital falls into. So video consultations and online consultations is something you can take advantage of. Apart from that, a patient should be taking regular rest and enough sleep, they should do enough exercises or walking. Now this is one very important thing which I have noted that during the lockdown period, many of our patients have not been doing the exercises or walking regularly. Because now after lockdown so many patients have been telling me that  I did have several lockdowns, the whole time we’ve been at home only. That leads to some weight gain because of no exercise and it also leads to raised glucose levels and which is seen in HbA1c. Some smart patients have been walking around in the home. Utilising the terrace or a facility where they can walk. Now again, in most parts of India or at least in the western region monsoons have set in. So again, rain may be a factor which may hinder patients moving out or walking around. So walking in the home is very important. Yoga is something another thing, which I recommend very strongly. And apart from that, in terms of diabetes patients, if they have flu symptoms, basically if they have fever, cough, any concern with breathing or breathing  difficulty, change in smell they should immediately contact the doctors or the concerned healthcare facility and follow their advice. Basically, some testing would be required, saturation would be checked, the vitals will be checked, and if the doctor feels COVID-19 swab test, if indicated would be done. So now again, coming back to our diabetes patients, any infection including COVID-19 would affect their glucose levels. So we need to keep checking our glucose levels regularly and It could be a very important indicator if they have an infection as well.

Speaker: Mr. Vivek
[15:05]

What would be the warning signs that diabetes patients should look for Specifically?

Speaker: Dr. Rahul
[15:10]

So again, before I go ahead, I would like to mention that around 80%-85% of patients may actually be asymptomatic those who are affected with COVID-19 which means they actually may have very little or may not have any symptoms at all, they may not have fever, they may not have cough, no breathlessness at all, and they will be absolutely fine and you cannot even make out that they have been affected with COVID-19. But those who have symptoms, they would of course have some cough, fever, or change in smell. Some patients also have alteration of taste, and so on. So in the diabetes patients of course, we have to look out for these symptoms apart from that, a very subtle sign could be fluctuating glucose levels. So for example, in the last few weeks or months, the glucose levels have been fairly stable, say morning glucose has been around 100-110 on fasting glucose levels. And during the day it’s fluctuating between 131-160 or postprandial can be up to 160-180. So these were the levels which the patient was on. Now suddenly the patient notices that the glucose has shot up to 200 -250, in that range, or if the patient also has hypoglycemia on and off, just a sudden onset, and along with that patient is noticing some cough or some flu like symptoms. Now, this is where probably you would suspect that there is an infection going on. Now, it can be a flu or any viral infection, not necessarily COVID-19. It could be any virus, which is very common in this weather. But of course, then the patient needs to approach medical health and let the doctors take it from there and decide whether COVID-19 tests would be required, or what would be the further line of finding. And of course, vitals need to be checked,  SpO2 needs to be checked. In many cases, a chest X-ray would be required because a lot of data has been accumulating COVID-19 affecting the chest and some findings there as well. So these are the pointers that diabetes patients should look out for.

Speaker: Mr. Vivek
[17:08]

What to do if a diabetes patient gets sick and shows symptoms of COVID-19? How should their family manage such a patient?

Speaker: Dr. Rahul
[17:18]

If the patient actually gets sick, and is showing symptoms of COVID-19, which means the patient either has fever, either has cough, or has some shortness of breath or a combination of these symptoms. First thing we should do is follow local guidelines and recommendations and immediately go to an appropriate medical facility and let the doctors examine you. And if there’s a setting that is the continuum of symptoms, and of course looking at the comorbidity which has diabetes, they will understand that the patient would probably be at higher risk of complications. If it actually turns out to be COVID-19 positive, now sometimes you know, depending on the condition of the patient, the patient might be sent back home with advice and quarantine measures and a follow up report would be sent. In some cases if the patient is actually not feeling well, or if the SpO2 too is low doctors may actually advise to admit such cases directly looking at the whole continuum. And once the patient is admitted they are started up with the drugs and some patients are requiring steroids as well. So then if the patient is admitted the doctors will initiate the treatment and if the patient is at home, of course, strict quarantine measures need to be taken care of, especially with the family contacts and all and the patient should monitor their glucose regularly. Be in touch with the doctor even online during that period because even if they’re quarantined, if the glucose levels are fluctuating, they need to be managed well because higher glucose levels means higher risk of complications. Another point to mention here would be to drink enough water. So adequate hydration should be maintained in these patients. Because many of the infections can cause dehydration, they will probably need to if the patient is quarantined at home. They will also need a SpO2 monitor which will monitor the saturation. Check it regularly, check their pulse and blood pressure also regularly . Eat their meals at regular times and rest enough. So these will be a few pointers if the patient does get infected. Most important for the family members will have to follow strict quarantine measures and minimize the contact with the patient.

Speaker: Mr. Vivek
[20:00]

Dr. Rahul talking to you was very informative. We learned about how diabetes patients are at risk of higher complications during COVID-19. We also learned about how to manage diabetes during these times. Thank you for talking to us.

Speaker: Dr. Rahul
[20:20]

Thank you, Vivek. It was my pleasure to be on Dr. Talks. I look forward to most discussions which can inform and educate our society.

Speaker: Mr. Vivek
[20:28]

Thank you. Dear listeners, please spread awareness about diabetes management during COVID 19 pandemic by sharing Dr. Talks podcast. You can visit us at www.drstories.com to hear and read interesting and informative talks and stories from our doctors. Cheers, till we meet next time.

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