182 CMAAO CORONA FACTS and MYTH Human Challenge
Dr K Aggarwal
With inputs from Dr Monica Vasudev
1048: New guidance from the UK National Diabetes COVID-19 Response Group: August 2 in Diabetic Medicine
1. 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 showed that dexamethasone reduced deaths in patients with COVID-19 on ventilators or receiving oxygen therapy. The dose used in RECOVERY — 6 mg daily for 10 days — is five- to six-fold greater than the therapeutic glucocorticoid replacement dose.
3. High glucocorticoid doses can exacerbate hyperglycaemia in people with established diabetes, unmask undiagnosed diabetes, precipitate hyperglycaemia or new-onset diabetes, and can also cause hyperglycaemic hyperosmolar state (HHS).
4. The guidance recommends a target glucose of 108-180 mg/dL and up to 216 mg/dL is "acceptable."
5. Use of once- or twice-daily NPH insulin is recommended for patients whose glucose has risen above 216 in some cases with the addition of a long-acting analog.
6. The guidance says that patients already taking premixed insulin formulations can continue using them while increasing the dose by 20% to 40%.
7. Given the risk of hypoglycaemia associated with those formulations, many experts say they would switch those patients to NPH during the time that they're on dexamethasone.
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