Risk of Death from COVID-19 Four Times Greater for Those with Diabetes

• New research has found that people with diabetes and poorly managed hyperglycemia who are hospitalized for COVID-19 have a death rate and longer length of hospital stay that’s four times higher than people without these conditions.
• Forty-two percent of those without a prior diagnosis of diabetes before being admitted, and who developed hyperglycemia during their time in the hospital, died.
• Experts say it’s important to limit the amount of time people with diabetes visit hospitals right now to protect themselves and healthcare workers, and to reduce strain on the healthcare system.

New research delves into the impact that diabetes and poorly managed hyperglycemia may have in people hospitalized for COVID-19.

The findings suggest a stark higher risk of death: The in-hospital death rate and longer length of hospital stay were more than four times higher for people with these conditions, according to a press release.

The peer-reviewed paper, backed by insulin management software company Glytec, was published last week in the Journal of Diabetes Science and Technology.

The researchers looked at 1,122 people hospitalized with COVID-19 in the United States from March 1 to April 6.

The data, collected from 88 hospitals in 11 states throughout the country, was sent to Glytec’s database. All study participants had a positive COVID-19 diagnosis.

Forty percent of participants had diabetes or hyperglycemia, which means high blood sugar levels, or had an A1C level at or greater than 6.5 percent.

The researchers say they defined hyperglycemia as two or more blood sugar readings that were greater than 180 mg/dL, read within any 24-hour period after being hospitalized.

What were the results?

People with diabetes and hyperglycemia had an in-hospital death rate of 29 percent, compared with just 6 percent for people who had neither condition.

One of the more startling figures from the report is that 42 percent of those without a prior diagnosis of diabetes before being admitted, and who developed hyperglycemia during their time in the hospital, died.

Looking closely at the data

Lead researcher Dr. Bruce Bode, FACE, diabetes specialist at Atlanta Diabetes Associates and adjunct associate professor of medicine at Emory University School of Medicine, told Healthline that while diabetes and hyperglycemia are risk factors for death in people with COVID-19 (and stress hyperglycemia does occur in people with no prior history of diabetes), it was that 42 percent death rate that was surprising.

“That’s nearly seven times higher than the mortality rate for patients with no hyperglycemia and no diabetes,” added Bode, who sits on the Scientific Advisory Board at Glytec.

Dr. Utpal Pajvani, an assistant professor of clinical medicine in the division of endocrinology at Columbia University, says the study’s suggestion that people with diabetes are at higher risk for health complications tied to COVID-19 tracks with findings seen in data from recent hospitalizations in China.

He calls the findings of this new report “important and timely observations,” but adds there are “significant limitations of these data.”

“For instance, these data are unable to distinguish between type 1 diabetes — caused by an autoimmune destruction of the insulin-producing pancreatic beta cells — and type 2 diabetes — typically caused by excess body weight, leading to resistance of the effects of insulin,” said Pajvani, who wasn’t affiliated with this research.

“Another limitation is that these data cannot distinguish between COVID-19 complications in well-controlled and poorly controlled diabetes,” he added.

Pajvani explains that when it comes to other infectious diseases, poorly managed diabetes is known to increase risk of other complications in general.

On the flip side, well-managed diabetes doesn’t, or at least leads to milder complications.

What people with diabetes should know about COVID-19

What does Pajvani recommend to his diabetes patients? He says he tells them to take “sensible precautions to avoid contracting COVID-19,” as with anyone else.

This means working from home if they’re able, maintaining safe physical or social distancing practices, and proper handwashing.

Beyond these recommendations, Pajvani stresses that they should try to maintain blood sugar levels “in the well-controlled range.” This would correspond to an A1C level less than 7 percent.

When it comes to what people should take away from the new research, Bode added, “It’s important to understand that the study did not identify simply living with diabetes as a risk factor for mortality; rather, uncontrolled diabetes and hyperglycemia as risk factors.”

Bode says that “as hospital systems fall into glycemic disarray during this crisis,” there’s a risk that people with type 1 diabetes who end up developing diabetic ketoacidosis (DKA) — a life threatening complication from diabetes — and need hospitalization “may see their condition managed differently than they would under normal circumstances.”

“That is why it is even more important to make sure that all patients have access to insulin and the medications and supplies they need to manage their glucose at home, so they can stay safe and out of the hospital,” Bode said.

Why healthcare providers are concerned

When asked whether the findings of the new study reflect what he’s seeing on the ground, Pajvani says “anecdotally yes.”

He echoes Bode in saying there’s an increasing number of cases in which COVID-19 has revealed preexisting diabetes or caused new onset cases, in some instances leading to DKA.

“Reasons for this require further study, and will keep my lab — and others — busy to figure out why this happens and how we can prevent it,” Pajvani added.

Bode says hospitals right now are justifiably concerned “with the need to balance glycemic management with the safety of healthcare workers, reduction in personal protective equipment (PPE) waste, and limiting unnecessary contact with patients.”

Until more is known about the impact poor glycemic management may have on outcomes of people with COVID-19, hospitals should “give serious consideration to following the national glycemic management guidelines,” he added.

Will glycemic management become more of a priority for hospitals? Pajvani says COVID-19 requires a lot of “supportive therapy” to improve a person’s oxygenation — that’s been the priority.

“But in patients with DKA, an equal priority is in management of this potentially life threatening condition,” he said.

Pajvani says when a person with diabetes is hospitalized, the management of their condition shifts from them to their healthcare team. In normal times, nurses and medical assistants check blood sugar levels several times each day.

But during this era, now these healthcare workers are putting themselves at increased risk with these multiple visits.

“Our inpatient diabetes team at Columbia, led by Dr. Magdalena Bogun, are implementing systems where these risks can be mitigated using continuous glucose monitoring,” Pajvani said. “This will allow better monitoring of the patient’s sugar level while reducing risk of COVID-19 transmission to the healthcare worker.”

Bode says that through insulin dosing software, people who are critically ill and receiving insulin through an IV usually see a complete resolution of their hyperglycemia within a matter of hours.

As a result of this normalized glucose, frequent checks made by hospital staff are less frequent.

“While there may be a tendency for healthcare workers to consider other, less intensive insulin therapies for this population, there is the risk that increased glycemic variability, hyperglycemia, and hypoglycemia could actually result in the use of more PPE, through longer patient stays and increased comorbidities,” Bode stressed.

Pajvani adds that typically in outpatient settings, one of the main responsibilities for providers is to ensure people maintain their blood sugar levels at target to prevent unnecessary visits to the emergency room.

This requires vigilance on both the part of provider and patient. Mitigating the amount of hospital visits is crucial now more than ever.

“I’m fortunate to work with outstanding nurses, diabetes educators, and front desk staff that goes above and beyond to help our patients stay safe. In fact, our outpatient practice is busier than usual, with telephone and video visits,” Pajvani said.

Moving forward, Bode says he and his team are working on several other research projects for diabetes and COVID-19.

They include how the current health crisis has changed how DKA is treated in people with type 1 diabetes, and how glycemic management affects how a person is affected by COVID-19.

The bottom line

New research from Glytec, published in the Journal of Diabetes Science and Technology, shows that the presence of diabetes and poorly managed hyperglycemia in people hospitalized with COVID-19 have led to starkly higher death rates and longer hospital stays.

Doctors say this reflects what they’ve been seeing anecdotally on the ground, another added challenge facing the healthcare community as the COVID-19 pandemic sweeps through the country.

Doctors say that, as with the general population, it’s important to limit the amount of time people with diabetes visit hospitals right now to protect themselves and healthcare workers, and to reduce strain on the healthcare system.

This means vigilant maintenance of their blood sugar levels.

As always, if you feel sick or think you might have COVID-19, contact your doctor.

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