COVID-19 ICU Admissions in Patients with Diabetes

Recent studies show a correlation between patients with diabetes and ICU admissions/mechanical ventilation for COVID-19 infections in the United States.

According to previous studies in the U.K., more than 20% of patients treated for COVID-19 in the intensive care unit have diabetes. Not only do patients with diabetes have a higher risk for ICU admissions, but also mortality and death rates. In a study conducted in Vanderbilt University Medical Center, patients with T1DM had higher risks for hospitalizations as opposed to patients without diabetes. In addition, high risks of diabetic ketoacidosis have been associated in patients with diabetes hospitalized for COVID-19. Both type 1 and type 2 diabetes can increase the adverse impacts of COVID-19, suggesting the need to diminish infection risk in this large group of patients. However, a U.S. nationwide study has not compared the severity of COVID-19 infection among patients with and without diabetes, as the variance in COVID-19 subtypes is different between the U.S. and U.K.

A recent study utilized the Premier Healthcare Database Special COVID-19 Release records of patients discharged after COVID-19 hospitalization nationwide in the U.S. between March and November 2020. The objective was to examine the risk of ICU admission or mechanical ventilation and death rates among patients hospitalized for COVID-19 with or without type 1/type 2 diabetes. This database comprises discharge records from various hospitals, representing about 25% of hospital admissions in the U.S. Exposure groups included patients with T1DM, no diabetes, and T2DM. Diabetes diagnosis and laboratory results from January 2019 were used. Descriptive analysis was used to differentiate demographic and clinical characteristics according to the type of diabetes. Multivariable logistic regression models were used to estimate the risk ratio and absolute risk difference of ICU/mechanical ventilation or mortality in patients hospitalized for COVID-19 between type 1 diabetes, type 2 diabetes, or no diabetes.

Among the 269,674 patients hospitalized for COVID-19, 1,849 had T1DM, while 110,843 had T2DM. During COVID-19 hospitalizations, insulin was dispensed to 86.5% of patients with T1DM, 78.4% with T2DM, and 12.9% without diabetes. Most patients were from urban hospitals (88.7%). Compared to patients without diabetes, those with T1DM were often younger and non-Hispanic Blacks with a higher prevalence of comorbidities. Compared to patients with T2DM, those with T1DM were often non-Hispanic Whites and had an increased risk for DKA. In the T1DM group, 60.2% required ICU or mechanical ventilation treatment, while the risk was lower for those without diabetes and T2DM (43.6% and 54.8%, respectively). Among patients with T1DM, the most extensive distribution in COVID-19 outcomes occurred in those less than 50 years of age, while the opposite was shown in those with T2DM or without diabetes. The absolute risk of ICU/mechanical ventilation among those with T1DM using age, sex, and race/ethnicity was 21% higher than those without diabetes (95% CI 0.19–0.24; absolute risk 65% vs. 44%) and 9% higher than patients with T2DM (95% CI 0.07–0.12). The absolute risk of death among those with T1DM using age, sex, and race/ethnicity was 5% higher than those without diabetes (95% CI 0.03–0.07; absolute risk 17% vs. 12%) and not significantly different than those with T2DM. However, after an adjustment for DKA occurring before or at COVID-19 diagnosis, patients with T1DM did not have an increased risk of ICU/mechanical ventilation (95% CI −0.01 to 0.03) and lower mortality (95% CI −0.05 to −0.01) as compared with patients who had T2DM.

This study concluded that patients with T1DM hospitalized for COVID-19 experienced higher mortality and risks for ICU/mechanical ventilation than patients without diabetes. Patients with T1DM had a higher risk for ICU/mechanical ventilation but no significant difference in mortality compared to patients with T2DM. The risk for ICU/mechanical ventilation and mortality was similar between patients with T1DM and T2DM when a history of DKA was considered. DKA was most present at COVID-19 admission in patients with T1DM, resulting from a possible relationship between COVID-19 and diabetes or delayed access to care during the pandemic. This study, however, lacked laboratory data that could identify DKA. In addition, patients who were undiagnosed with diabetes but had uncontrolled hyperglycemia were included in the no diabetes group, affecting how the authors analyzed the severity of COVID-19 upon admission. Future studies should focus on the duration of diabetes, which could account for higher ICU/mechanical ventilation rates in COVID-19 infections.

Practice Pearls:

• Previous studies in the U.K. have shown a correlation between diabetes and COVID-19 infection rates
• A study conducted in the U.S. showed that patients with T1DM and hospitalized for COVID-19 were at a higher risk of ICU/mechanical ventilation and mortality than patients without diabetes.
• Clinical studies analyzing the association between diabetes and COVID-19 can emphasize the severity of COVID-19 among those with comorbidities and guide clinical care.

Barron, Emma et al. “Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a whole-population study.” The lancet. 

Gregory, Justin M et al. “COVID-19 Severity Is Tripled in the Diabetes Community: A Prospective Analysis of the Pandemic’s Impact in Type 1 and Type 2 Diabetes.” Diabetes care

Barrett, Catherine E et al. “Intensive Care Unit Admission, Mechanical Ventilation, and Mortality Among Patients With Type 1 Diabetes Hospitalized for COVID-19 in the U.S.” Diabetes care

Dalia Elabed, PharmD Candidate 2022, University of South Florida Taneja College of Pharmacy