CMAAO Coronavirus Facts and Myth Buster: Steroid and Diabetes

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With inputs from Dr Monica Vasudev

1048: New guidance from the UK National Diabetes COVID-19 Response Group [August 2 in Diabetic Medicine]

  1. Address the triple insult of dexamethasone-induced impaired glucose metabolism, COVID-19-induced insulin resistance, and COVID-19 impaired insulin production.
  2. Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial revealed that dexamethasone led to reduction in deaths in patients with COVID-19 on ventilators or receiving oxygen therapy. The dose used in the trial was 6 mg daily for 10 days, which is 5 to 6 times greater than the therapeutic glucocorticoid replacement dose.
  3. High glucocorticoid doses can result in exacerbation of hyperglycemia in those with established diabetes, can unmask undiagnosed diabetes, cause hyperglycemia or new-onset diabetes, and can also lead to hyperglycemic hyperosmolar state (HHS).
  4. The guidance recommends a target glucose of 108-180 mg/dL and further states that up to 216 mg/dL is acceptable.
  5. It recommends the use of once- or twice-daily NPH insulin for patients with glucose above 216, in certain cases with the addition of a long-acting analog.
  6. Patients already taking premixed insulin formulations can continue, while increasing the dose by 20% to 40%.
  7. Considering the risk of hypoglycemia associated with those formulations, many experts say that they would switch those patients to NPH during the time theyre being given dexamethasone. [Medscape Excerpts]

Comments

  1. Steroid induced high sugar is often post meals.
  2. Give repaglinide 1 mg or 2 mg sublingual before meals.
  3. Add 0.3 units insulin per kg in divided doses.
  4. In high-risk cases steroids may have to be started on day 1 itself so adjust dose accordingly.
  5. In post COVID illness, steroids may have to continue for weeks together like in any immunological illness.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

Minimizing Hypoglycemia in Diabetes

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The US Department of Health and Human Services has identified hypoglycemia as one of the top three preventable and measurable adverse drug events in a recent article published in the December 11 issue of the Journal of Clinical Endocrinology and Metabolism.

Hypoglycemia is defined in

  • Level 1: Glucose < 70 mg/dL and ≥ 54 mg/dL
  • Level 2: Glucose < 54 mg/dL; needs immediate action.
  • Level 3: A severe event characterized by altered mental and/or physical status requiring assistance.

Remember the three measures:

Measure 1:

Identify high risk patients

  • First assess if the patient has experienced a previous Level 2 or Level 3 hypoglycemic event within the past year. If not, then proceed to;
  • Second, if the patient has a prescription for insulin and/or insulin secretagogues and has an A1c < 7% documented within the past 6 months. If not, then proceed to;
  • Third, if the patient has a prescription for insulin and/or insulin secretagogues and at least one relevant comorbidity.

Measure 2: Educate patients (65+) and care givers who are at greater risk for hypoglycemia

Measure 3: Encourage patients to report hypoglycemic events

Dr KK Aggarwal

Padma Shri Awardee

President Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

People with diabetes must be cautious during Ramadan fasting: HCFI

Health Care, Heart Care Foundation of India, Medicine Comments Off

Precautions and consultation with physician are advised

New Delhi, 18th May 2019: India has the third-largest Muslim population according to statistics, and a majority of them will be fasting during Ramadan. This number will also constitute people living with diabetes and thus, the need of the hour is to fast while exercising caution. Fasting can bring about metabolic changes and they must adjust their diet plan during Ramadan.

There is a 12- to 15-hour gap in between meals which can become a problem for those with diabetes. It is therefore advised that they consume regular and timely meals. People with Type 1 diabetes are at a higher risk compared to those with type 2 when fasting during the holy month.

Speaking about this, Padma Shri Awardee, Dr KK Aggarwal, President, HCFI, said, “Ramadan this year will continue till the month of June and the fasting period will be longer due to daylight hours. It is imperative that people living with diabetes consult their doctor and monitor blood glucose levels regularly. People with type 1 diabetes and a history of recurrent hypoglycemia have a higher risk during fasting. In those with Type 2 diabetes, there is a likelihood of hypo- and hyperglycemia. A patient’s decision to fast should be made after ample discussion with his or her physician concerning the risks involved. Patients who insist on fasting should undergo pre-Ramadan assessment and receive appropriate education and instructions related to physical activity, meal planning, glucose monitoring, and dosage and timing of medications. The management plan must be highly individualized. Close follow-up is essential to reduce the risk for development of complications.

Some symptoms to be noted include fluctuating blood sugar levels, seizures and unconsciousness; blurry vision, headache, sweating, increased fatigue, and thirst. In case any of these persist, the patient should do away with fasting completely.

Adding further, Dr Aggarwal, who is also the Group Editor-in-Chief of IJCP, said, “Thirty days of Ramadan in Islam; nine days of Navratra in Hinduism and forty days of Easter in Christianity are spiritual practices observed by respective religions. These are days of mind, body and soul detoxification observed as per religion defined rituals. Broadly, they involve restraining the ten senses during the fast period. One restrains from negative thoughts cum actions and indulges in positive thoughts cum actions.

In Ramadan, the one-month continuous fast detoxifies the mind, body and soul and reenergizes the human being. Taking precautions can help people exercise better control over their health conditions even during fasting.

Some tips from HCFI

  • Monitor blood sugar level frequently.
  • Do not overeat. Pay attention to body signals and understand hunger.
  • Make sure to break the fast with sugar-free and decaffeinated drinks to avoid dehydration
  • Consume sweets in a limited amount.
  • Make sure to include lot of fruits, vegetables, pulses, and curd in your diet
  • Allow a time interval of at least 2 hours between the meal and bedtime. It is a good idea to avoid complex carbohydrates right before bedtime.
  • Avoid deep fried foods. Also, make sure to time the consumption of starch-containing foods such as rice and rotis.

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