Ask the expert: Meet Prof. Cohen

Professor Ohad Cohen, Clinical Professor of Medicine Ch. Sheba Medical Centre Tel Hashomer (Israel) and Director of Medical Affairs at Medtronic Diabetes EMEA, shares some of the most frequently asked questions (FAQ) on COVID-19 and its effect on type 1 diabetes (T1D).

“Publications are emphasising that diabetes is a risk factor for contracting the COVID-19 and suffering from complications. What does it mean for people living with type 1 diabetes? Am I in danger?”

• What we need to remember is that COVID-19 is a new disease, and because it’s a new disease we don’t have detailed epidemiological information. There are a lot of unknowns, but there is no reason to worry.
• From what we have seen so far, it seems that people living with diabetes are not at a higher risk of getting the disease. 
• When we are talking about complications, or having bad outcomes, we are referring to people with type 2 diabetes. People in this group are more likely to be hospitalised and suffer complications. It must be made clear that higher risk of complications in type 2 diabetes has always been there, even before COVID-19. People in this group are usually older, and have secondary diseases, such as heart and kidney disease, making them more vulnerable.

“I have type 1 diabetes. Should I consider taking any protective measures during this COVID-19 pandemic?”

• Everyone should be taking protective measures at this stage.
• The virus can spread through droplets up to 1 metre¹. This is why everyone must keep a social distance of 1-2 metres^1,2. 
• I would also recommend wearing a face mask when you are around other people when possible. Please follow the UK and Ireland government recommendations as well.
• The virus can stick to surfaces and clothing so washing your hands with soap is very important. Cleaning surfaces with >60% containing alcohol gels will also destroy the virus. You should follow the UK and Ireland government recommendations as well.

“Should I be expecting a change in my glucose control during COVID-19?”

Yes, you can expect a change in glucose control. This pandemic has caused the closure of schools, academic centres and gyms. There is also a restriction on using parks. We have had to adapt to spending more time indoors. Our physical activity is reduced, our stress levels can increase, and our eating habits can change, all these factors influence our glucose levels. 

What I would recommend:

1. Anticipate some decrease in glucose control.
2. Create and stick to a routine.
   Your routine should include regular mealtimes, rest time and exercise. You should avoid frequent snacking (especially carbohyrates). 
3. Adjust your therapy
   I would recommend adjusting the basal rate first. Many clinics have been adjusting to the current situation of limited travel and quarantine, by providing remote services- if possible, connect with your healthcare professional in this way.  
   For users of sensor augmented pumps such as MiniMed^TM 640G system, I would recommend changing the insulin pump setting (with the supervision of your Health Care Professional), after looking at your current pattern for 3-4 days. Please allow sometime for the changes to take effect. Until then, use correction boluses if needed. These correction boluses should also be taken into consideration when implementing the changes to your settings. 
   When using MiniMed^TM 670G system- let the algorithm correct glucose levels on a daily basis and then periodically asses with your Health Care Professional to determine the need to adjust the pump settings. There is no need to exit Auto Mode, but, more frequent correction might be required while the algorithm is adapting to the new daily circumstances.

“What if I have COVID-19? How do I take care of my glucose levels?”

What we need to remember is that most cases are mildly symptomatic. If you are COVID-19 positive, you need to assess how severe your symptoms are and act accordingly. Of course- always consult your medical care team. 

• If you have mild symptoms:

  This may include having a fever, dry cough, loss of smell and taste senses, general ill feeling, such as loss of appetite, muscle aches. At this stage, you do not need to make major changes to your ongoing insulin routine. You should continue to follow your normal recommended insulin therapy. You should also count carbs, and bolus using the Bolus Wizard^TM for meals and corrections. Remember to drink lots of water and stay hydrated. You will need to monitor your blood glucose closely. Discuss immediately with your health care professional if you are taking non-insulin antidiabetic medications, notable SGLT-2 inhibitors and GLP-1 agonists.

• Measure Ketones.

  COVID-19, does not, usually, effect the gastrointestinal tract, but if you experience vomiting and diarrhoea measure ketones and follow the appropriate care. It might not be related directly to COVID-19.

• If you have trouble breathing

  Rarely, mild cases can deteriorate rapidly into a respiratory disorder called ARDS. The two most common symptoms to look for are an increase in fever and shortness of breath (beyond the dry cough). In this case please seek immediate medical attention. 

• Make use of basal/ bolus regimens 

  Right now, the medical facilities in your area may be functioning in an emergency mode. This may include reducing regular working times or closing a few services. This means your usual endocrinological consult service could be unavailable. It may also mean that the available treating staff may not be familiar with the device you are using. If this happens, please be prepared to carry out your back-up basal/bolus routines. If you do not have a basal/bolus routine, please consult your Health Care Professional.

We hope that this has answered some of the questions you may have had on COVID-19 and its impact on diabetes management. 

^{Reference 
1.    World Health Organization. Advice for public. April 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public [Accessed April 2020].
2.    Public Health England. Staying at home and away from others (social distancing). April 2020. https://www.gov.uk/government/publications/full-guidance-on-staying-at-home-and-away-from-others/full-guidance-on-staying-at-home-and-away-from-others [Accessed April 2020]}