Summary of COVID-19 medicines guidance: Diabetes

Abigail Scott, Regional Medicines Information Pharmacist, Midlands and East Medicines Advice Service (East Anglia site)Published

This page summarises and signposts to medicine related guidance we’re aware of from professional and government bodies relating to coronavirus and diabetes.

Our advice is constantly reviewed as the pandemic situation evolves.

Whilst we have tried to ensure that the information on this page is complete, please report a concern if you feel anything is omitted or inaccurate.

To see our professional guidance summaries for other clinical areas, click here

Advice in this area includes:

Diabetes UK: Updates: Coronavirus and diabetes

Last update 3rd December 2020 [no changes in advice and information relating to medicines since last update]

Advice for patients

  • Links to information on how steroids (including dexamethasone for Covid) may affect diabetes control.
  • Information for patients on obtaining medicines and related technology (e.g. insulin pumps) during lockdown.
  • Links to a news page on the Coronavirus vaccine.

Diabetes UK: Advice for healthcare professionals on coronavirus (COVID-19) and diabetes

Contains no updated date [no changes in advice and information relating to medicines since last update]

  • This contains primarily links to diabetes management in COVID-19 such as in patients with pregnancy or mental health.
  • Also contains links to all the guidelines produced by the National Inpatient Diabetes Covid-19 Response Team (including Diabetes UK, Association of British Clinical Diabetologists (ABCD) and Joint British Diabetes Societies (JBDS)). These are referenced below next to ABCD, but a different provider hosts the documents, i.e. may still be accessible if the alternate host is unavailable.
  • Patient advice on managing SGLT2i is summarised as patients should stop taking SGLT2i tablets if they become unwell because of increased risk of diabetic ketoacidosis.

Diabetes UK: COncise adVice on Inpatient Diabetes (COVID:Diabetes): FRONT DOOR GUIDANCE

Joint guideline produced by Diabetes UK, Joint British Diabetes Societies, and Association of British Clinical Diabetologists.

Last update 17th November 2020 (v3.1)

  • See below for summary

Association of British Clinical Diabetologists (ABCD): COVID-19 (Coronavirus) Information for Healthcare Professionals

Nil date of publishing / update specified

  • This has links to various guidelines available (see below). These are duplicated on the Diabetes UK website (above).

 

ABCD: COncise adVice on Inpatient Diabetes (COVID:Diabetes): FRONT DOOR GUIDANCE

Joint guideline produced by Diabetes UK, Joint British Diabetes Societies, and Association of British Clinical Diabetologists.

Last update 17th November 2020 (v3.1)

  • Persistently high glucose levels may need treatment with subcutaneous or intravenous insulin. If infusion pumps for intravenous insulin are not available to manage hyperglycaemia, use alternative s/c regimens to manage hyperglycaemia and mild DKA.
  • Stop SGLT-2 inhibitors (Cana-/Dapa-/Empa or Ertu-gliflozin)
  • Stop metformin in all people admitted to hospital but after satisfactory review of blood lactate, renal and hypoxic status, recommence treatment, as recent data suggests that metformin may reduce progress to severe COVID-19 disease.
  • ACE inhibitor and ARBs do not worsen COVID-19 disease but their use, and the use of NSAIDs, must be reviewed in the individual clinical context
  • Never stop basal insulin in patients with known type 1 diabetes – DKA may result.
  • If ketosis persists despite treatment in line with usual protocols then consider using 10-20% glucose.
  • Managing blood ketone levels: if blood ketones are 1.5 – 2.9mmol/L – consider rapid-acting insulin if glucose above 16mmol/L. Note: glucose can be <11mmol/L if patients are on SGLT-2 inhibitor treatment, are pregnant and/or have severe COVID-19 infection.
  • If patients are unable to manage their personal insulin pump and no specialist advice is immediately available, start a VRIII or S/C basal-bolus insulin regimen then remove the pump and store it safely. If S/C regime required and not able to find out total daily insulin dose from pump then the following would be safe: calculate total daily insulin dose using 0.5 units/kg and give half the total dose as basal/background insulin and half as bolus/mealtime rapid acting insulin. Ensure that pump is disconnected after S/C basal insulin given.

ABCD: COncise adVice on Inpatient Diabetes (COVID:Diabetes): Guideline for managing DKA using subcutaneous insulin (where intravenous insulin infusion is not possible)

Last update 29 April 2020 (v3.3)

Please note this guideline is for use in COVID-19 suspected/positive people and those without COVID-19 disease when a diagnosis of DKA has been confirmed.

  • Fluid replacement: fluid should be replaced intravenously – for rates see tables provided in guideline (page 2).
  • Subcutaneous doses of rapid-acting insulin analogues (Novorapid® /Humalog® /Apidra®):
    • Initial dose of 0.4 units/kg every 4 hours.
    • Reduce to 0.2 units/kg every 4 hours once glucose is less than 14mmol/L.
    • Continue until ketones less than 0.6 mmol/L.
    • If ketones not falling as expected increase rapid acting insulin dose to 0.5 units/kg every 4 hours.
    • Consider switching to IV insulin if infusion pump available.
  • Basal insulin – always start / continue long-acting insulin when treating DKA
    • If using regular injectable long-acting insulin – continue.
    • If not previously using basal insulin initiate a dose of 0.15 units/kg/day.
    • If using a personal insulin pump EITHER continue basal insulin rate via pump if the patient can safely manage this themselves. OR switch to S/C basal insulin regime – find the usual total daily basal insulin dose and use the same dose of injectable basal insulin. If unable to find total basal insulin dose, give a total daily basal insulin dose of 0.25 units/kg. Options are twice daily Levemir® or once daily Lantus® / Abasaglar® /Semglee®.
  • The effect of COVID-19 disease on potassium regulation remains unknown, therefore potassium replacement should follow standard protocols and be guided by 2 hourly monitoring.

ABCD: COncise adVice on Inpatient Diabetes (COVID:Diabetes): Guidance for managing inpatient hyperglycaemia

Last update 29 April 2020 (v4.2)

  • If glucose > 12 mmol/L and no insulin administered in previous 4 hours, consider a corrective dose of rapid-acting analogue insulin (Novorapid® /Humalog® /Apidra®). Dose is decided using table from guideline (page 1).
  • Long-acting insulin (Levemir®/ Abasaglar®/Lantus®/Semglee®/ Humulin I®/Insulatard®/Insuman Basal®):
    • If already on long acting insulin, continue and titrate dose (see table on page 1)
    • If not already using long-acting insulin – If 2 or more glucose readings in 24 hours are > 12 mmol/l add long-acting insulin – total dose 0.25 units/kg/day. If >70 years, frail, or serum creatinine >175 umol/L – use reduced dose of 0.15 units/kg.
  • Doses can be titrated for long-acting insulin daily, although longer-acting insulins may take 48-72 hours to reach steady state. Dose adjustments will affect blood glucose throughout the day. See tables on page 2 for dose adjustments.

ABCD: COncise adVice on Inpatient Diabetes (COVID:Diabetes): Dexamethasone/Glucocorticosteroid Therapy in Covid-19 Patients – implications and guidance for the management of blood glucose in people with AND WITHOUT Diabetes

Last update 20 November 2020 (v2.3)

  • This guidance is for use in ALL patients with COVID-19 who are treated with dexamethasone in a ward setting. It is NOT intended for Critical Care Units but may be adapted for this use. Contains guidance on frequency of blood glucose monitoring and target range as well as treatment.
  • In combination, high-dose glucocorticoid-therapy-induced impaired glucose metabolism, COVID-19 induced insulin resistance and COVID-19 related impaired insulin production could result in significant hyperglycaemia, HHS and DKA in people with and without diabetes, increasing both morbidity and mortality.
  • Sulphonylureas are NOT recommended in this context as beta cell function may be impaired and insulin resistance is likely to be severe.
  • In contrast to the COVID:Diabetes Guidance for Managing Inpatient Hyperglycaemia previously published, this guidance recommends larger insulin doses to overcome the greater insulin resistance which may be encountered in many patients treated with high doses of glucocorticoids and should ONLY be used in this context.
  • Authors emphasise this advice is CONSERVATIVE. If after initial treatment hyperglycaemia persists, do not hesitate to escalate to the next treatment step and involve the diabetes team as early as possible.
  • If Diabetic Ketoacidosis and Hyperglycaemia Hyperosmolar Syndrome have been ruled out, use a subcutaneous rapid acting insulin analogue (Novorapid®/Humalog®/Apridra®) as described in the table on page 2 for correcting initial hyperglycaemia (glucose above 12mmol/L).
  • For maintaining glycaemic control, for people NOT already on an intermediate acting (NPH) or long acting insulin, where glucose has risen above 12.0 mmol/l due to dexamethasone, start NPH insulin which has an intermediate duration of action (e.g. Humulin I®, Insulatard®). 0.3 units/kg/day is conservative, but experience suggests that a dose of 0.5 units/kg/day or more may be required depending on severity of illness, BMI and pre-existing diabetes control as indicated by HbA1c. Give two-thirds of the total daily dose in the morning and the remaining one-third in the early evening. If older (>70 yrs), frail, or serum creatinine >175 umol/l (eGFR <30 ml/min), use a reduced NPH insulin dose of 0.15 units/kg. There should be a low threshold for dose escalation (see table on page 3) and referral to the diabetes team.
  • For people already using once or twice daily long-acting insulin or twice daily NPH including those on basal-bolus regimens, increase the long acting basal or NPH insulin by 20% but this may need rapid escalation by as much as 40% depending on response. Titrate the dose using the tables on page 3.
  • For people on twice-daily pre-mix insulin (e.g. e.g. NovoMix 30®/Humulin M3®/Humalog Mix 25®/Humalog Mix 50®), continue mixed insulin and adjust dose (follow dose adjustment for long-acting insulin table on page 3). Consider increasing the morning dose by 20% but this may need rapid escalation by as much as 40% each day depending on the response. There should be a low threshold for referral to the diabetes team.
  • After glucocorticoid therapy is stopped insulin resistance and requirements usually fall gradually requiring a gradual reduction in insulin requirements, however in COVID-19 patients a faster and a more aggressive reduction in insulin may be necessary. From day one, the total insulin dose may need to be reduced by as much as 50% guided by ‘pre-steroid’ insulin requirements. Subsequent insulin dose changes should be guided by 6 hourly glucose monitoring and input
    from the diabetes specialist team.
  • Document also contains guidance for monitoring after discharge and follow up.

ABCD: A Covid-19 Response Action – Diabetes Management in Care Homes

Last update 12 May 2020

  • Advice for care home managers is to have available a hypoglycaemia treatment kit plus intramuscular (IM) glucagon, and replenishing this every time it is has been used.

Management of hyperglycaemia (Table B – page 3)

  • For stable, non-COVID 19 residents – continue usual diabetes treatment.
  • For COVID-19 positive and stable residents – Continue usual diabetes treatment even if they have reduced appetite, but regular monitoring is required to avoid high and low blood sugars.
  • For COVID-19 positive and unwell residents on oral therapy – Initially, adjust oral hypoglycaemic medications and ensure regular and frequent testing of blood sugar.
  • For COVID-19 positive and unwell residents on insulin – Continue insulin at usual dose, closely monitor blood glucose; seek local diabetes nursing team support/advice for further management.
  • For COVID-19 positive and unwell residents unable to take oral therapy – Seek local diabetes nursing team support/advice for further management; replace oral therapy by a basal long-acting analogue insulin starting at a daily dose of 0.15 units/Kg body weight.
  • For COVID-19 positive residents on any therapy but with erratic eating patterns and fluctuating surges of blood glucose – Seek local diabetes nursing team support/advice for further management; continue their usual hypoglycaemic therapy. Short-acting insulin can be given subcutaneously as required in boluses of up to 6 units or greater depending on local diabetes nursing advice.

Management of hypoglycaemia:

  • Residents receiving insulin or sulphonylureas (e.g. gliclazide, glipizide) or glinides (e.g. nateglinide) have a higher risk of hypoglycaemia particularly if their usual meal pattern is disturbed through acute illness or nausea.
  • If unconscious or fitting – stop any scheduled insulin, give 1mg glucagon IM once only if possible.

End of life care:

  • For residents with type 2 diabetes, stop all oral glucose-lowering therapy and GLP-1 RA (glucagon-like peptode-1 receptor agonist, e.g. exenatide, liraglutide) injections; for those taking a small dose of daily insulin, consideration should also be given to stopping this insulin by discussion with local team responsible for diabetes care.
  • For residents with type 1 diabetes, treatment with insulin should be continued but consideration given to simplifying the regimen and switching to a once-daily dose long-acting insulin analogue such Insulin Glargine (Lantus) or Insulin Degludec (Tresiba).
  • Stop all routine blood sugar testing in those with type 2 diabetes on diet and/or metformin; in other cases where there are no prospects of recovery, consideration should be given to stopping all blood sugar testing.

Administration update (12th Jan 2021): administrative changes made only.