Clinical Effectiveness of a Protocol to Manage Deamthasone-Induced Hyperglycemia Among Hospitalized Patients With COVID-19

Abstract

Importance: Well-controlled glucose levels during hospitalization (i.e. 70–180 mg/dl) have been associated with lower mortality in patients with COVID-19. The recent addition of dexamethasone to COVID-19 treatment protocols has raised concerns about the negative metabolic consequences of dexamethasone including hyperglycemia. We developed a simplified, yet comprehensive, protocol to guide the management of dexamethasone-induced hyperglycemia in hospitalized patients with COVID-19. Objectives: To present our protocol for the management of dexamethasone-induced hyperglycemia and examine its clinical effectiveness in the real world. Methods: An algorithm-based protocol that outlines all aspects of the inpatient management of dexamethasone-induced hyperglycemia in COVID-19 patients, from time of admission to discharge including guidance on insulin titration, was disseminated to the COVID-19 teams in our hospital. Medical records of 163 patients admitted between June and September, 2020 who tested positive for COVID-19 and developed dexamethasone-induced hyperglycemia were reviewed. Fasting, pre-lunch, pre-dinner and bedtime glucose levels during the first five days of admission and day of discharge were compared between the 47 patients who were managed “Pre-Protocol” implementation and the 116 patients who were managed “Post-Protocol” implementation. Results: On admission, there were no significant differences in age, proportion of women, BMI, prevalence of diabetes, and Charlson score between the “Pre-Protocol” and “Post-Protocol” groups (56 vs 56 years old, 30 vs 32% women, 28 vs 29 kg/m2, 45 vs 35% with diabetes, and 2 vs 2 median Charlson scores; respectively, all p>0.05). The “Post-Protocol” group had higher proportions of patients with well-controlled glucose (i.e. 70–180 mg/dL) compared to the “Pre-Protocol” group, across all pre-meals and bedtime glucose readings throughout the hospital stay. The differences between the “Post-Protocol” and “Pre-Protocol” groups were statistically significant (p<0.05) for fasting glucose on day 4, 5, and discharge day; pre-lunch glucose on discharge day; pre-dinner glucose on day 3, 5, and discharge day; and bedtime glucose on day 1. In regression analyses adjusted for age, sex, nationality, BMI, Charlson score, and diabetes status, the odds ratios of having well-controlled glucose were significantly higher in the “Post-Protocol” group versus the “Pre-Protocol” group for fasting glucose on day 4, 5, and on discharge; pre-lunch glucose on day 5 and on discharge day; pre-dinner glucose on day 3 and 5; and bedtime glucose on day 1. Conclusion: The implementation of a simplified protocol for the management of dexamethasone-induced hyperglycemia in hospitalized patients with COVID-19 results in more patients achieving well-controlled glucose levels that have been previously associated with lower mortality of COVID-19.