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Possible Link Connecting COVID-19 and New-Onset Diabetes

Sep 22, 2020
 
Editor: Steve Freed, R.PH., CDE

Author: Brianna Belton, PharmD. Candidate, Florida Agricultural & Mechanical University, College of Pharmacy and Pharmaceutical Sciences

CoviDIAB Registry will explore why COVID-19 can increase complications in people with pre-existing diabetes, and may also be driving new cases. 

A bidirectional relationship exists between COVID-19 and diabetes. Diabetes is a risk factor, associated with increased severity and mortality, for those who contract COVID-19. On the other hand, those with COVID-19 are at an increased risk of new-onset diabetes and increased risk of complications associated with pre-existing diabetes. Emerging evidence suggests that COVID-19 may lead to new-onset diabetes in healthy patients and patients with pre-diabetes, and cause severe complications in patients who already have diabetes, which has something to do with the pathophysiology of the virus. 

To understand this relationship, a Global Registry has been established. The registry will include patients with COVID-19-related diabetes, as well as patients who previously had diabetes, to investigate the relationship optimally. This international research project, the CoviDIAB Registry project, aims to gather enough data from all over the world to assess the pathogenesis, management, and outcomes related to COVID-19 and diabetes. This includes, but is not limited to, the prolonged effects after the complications of the virus and diabetes subside, whether the new-onset diabetes is a different type of diabetes, and the impact of different phenotypes present at presentation and during recovery. The data obtained will be used to determine the plan for statistical analysis and determine the design of future studies.  

What is understood to date is that there is an involvement of SARS-CoV-2. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that causes COVID-19. This virus binds to angiotensin-converting enzyme 2 (ACE2) receptors. These receptors are expressed in critical metabolic organs, including pancreatic beta cells, which can help explain why glucose metabolism could be altered. 

One study that displays this phenomenon is a case report, Diabetic ketoacidosis precipitated by Covid-19 in a patient with newly diagnosed diabetes mellitus, a patient diagnosed with diabetic ketoacidosis (DKA) after presenting with symptoms of COVID-19 one week prior. A previously healthy patient presented with DKA, a metabolic complication due to insulin deficiency and uncontrolled blood glucose, primarily in patients with type 1 diabetes. After resolving the patients DKA, the patient was started on insulin therapy. Based on the patients presentation, the author concluded that SARS-CoV-2 might have disrupted the pancreatic betacell function resulting in DKA. Pathophysiology still needs to be determined.  

Another study is a retrospective cohort study; COVID19 infection may cause ketosis and ketoacidosis. In this study, patients positively diagnosed with COVID-19 were investigated to determine the metabolic diseases caused by COVID-19. There were 658 hospitalized patients. Of these patients, 42 presented with ketosis on admission, with 15 being previously diagnosed with diabetes. Three out of the 15 patients with diabetic ketosis developed acidosis. Out of the 27 patients with non-diabetic ketosis, two developed severe acidosis; ketosis results when ketone consumption decreases. Patients will present with elevated blood concentrations of ketone bodies. Ketoacidosis results from the accumulation of ketone bodies and acidosis, mostly present in patients with diabetes.  

Based on this cohort study, it was concluded that COVID-19 caused ketosis or ketoacidosis in patients without diabetes and induced DKA in patients with diabetes. Ketosis was shown to increase the length of hospital stay and mortality. Diabetes was shown to increase the length of hospital stay without affecting mortality.  Also, for patients to present with ketoacidosis without having diabetes, it suggests that COVID-19 might accelerate the breakdown of fat and induce ketosis, which can further develop into ketoacidosis. 

Given that COVID-19 is at its infancy, further research is needed to definitively say what the real relationship between diabetes and COVID-19 is. The CoviDIAB Registry project is a promising international initiative to be able to establish this relationship. Hopefully, there are more studies, as well, to be able to observe and determine appropriate strategies for treatment. DKA and COVID-19 are two very life-threatening complications, and if they are likely to exist together, it is essential to decide on the appropriate treatment strategies. In time this relationship will be established, and the complications associated with COVID-19 and Diabetes will be drastically reduced and appropriately managed.  

Practice Pearls: 

  • It is important to pay close attention to patients with COVID-19 and diabetes because of the increased risk of severity, complications, and mortality. 
  • To fully understand the mechanism of COVID-19-induced acidosis and ketoacidosis, more research is needed. 
  • A Global Registry, CoviDIAB Registry, has been established to gain insight into the relationship between COVID-19 and Diabetes. 

 

Chee, Ying Jie, et al. “Diabetic Ketoacidosis Precipitated by Covid-19 in a Patient with Newly Diagnosed Diabetes Mellitus.” Diabetes Research and Clinical Practice, vol. 164, 2020, p. 108166., doi:10.1016/j.diabres.2020.108166. 

Li, Juyi, et al. “COVID 19 Infection May Cause Ketosis and Ketoacidosis.” Diabetes, Obesity and Metabolism, 2020, doi:10.1111/dom.14057. 

Mallapaty, Smriti. “Mounting Clues Suggest the Coronavirus Might Trigger Diabetes.” Nature, 2020, doi:10.1038/d41586-020-01891-8. 

Rubino, F. et al. “New-Onset Diabetes in Covid-19” New Engl. J. Med. 2020, doi:10.1056/NEJMc2018688 

 

Brianna Belton, PharmD. Candidate, Florida Agricultural & Mechanical University, College of Pharmacy and Pharmaceutical Sciences