Diabetes care during the outbreak of 2019 novel coronavirus disease (COVID‐19) in Taiwan

Abstract

Coronavirus disease 2019 (COVID-19) is now a global pandemic which is imposing a heavy burden on medical resources. The total number of reported COVID-19 cases as of April 16, 2020 is more than 2.07 million with 137 666 deaths worldwide, including a total of 395 cases and 6 deaths in Taiwan.1 The first fatal case of COVID-19 in Taiwan occurred on February 16, 2020, and was a taxi driver with no history of travel who was infected by a passenger who had just arrived back from Wuhan, China. This case raised the concerns of clinicians about a higher risk of severe complications and mortality in patients with diabetes mellitus.2 Patients with diabetes are considered to be at high risk of acquired infections, possibly due to poor glucose control. In addition, patients with diabetes have an impaired immune-response to infection both in relation to changes in cytokine profile, T-cell and macrophage activation. Hyperglycemia reduces chemotaxis and the activation of polymorphonuclear neutrophils, and thus diabetic patients have higher rates of morbidity and mortality due to infections. In addition, most patients with diabetes develop co-morbidities over time, including hypertension, dyslipidemia, obesity and cardiovascular disease. The number of comorbidities is a predictor of mortality in patients with COVID-19. Taiwan is one of few nations where the outbreak is still under control, and the Taiwan Centers for Disease Control (CDC) has played an important role by implementing a series of public health policies.1 In this article, we discuss how these policies have affected the routine standard care of diabetes. As there is currently no validated therapy for COVID-19 besides supportive care, preventing infection is the major concern. According to the CDC prevention guidelines, washing hands and wearing a medical-grade face mask if experiencing respiratory symptoms and going to see a doctor are recommended. To decrease the patient's exposure in an institutional setting, clinicians can defer non-urgent laboratory tests in patients with good compliance and stable clinical condition. For those in whom examinations are necessary, clinicians can arrange to have blood drawn on the same day as the return visit or when collecting a repeat prescription. Furthermore, clinicians can consider deferring medical examinations which need close contact, such as funduscopic examinations. It is common in clinical practice for patients to neglect chronic disease control such as diabetes mellitus, causing the condition to become more severe. For example, they may stop taking anti-diabetic medications resulting in acute complications such as diabetic ketoacidosis and hyperosmolarity hyperglycemic crisis. Coronavirus binds to target cells through ACE2, which is expressed in epithelial cells in the lungs, blood vessels and intestine. In patients treated with ACE and angiotensin II receptor blockers, a first-line anti-hypertensive medication for patients with diabetes, the expression of ACE2 is increased,3 which can then accelerate COVID-19 infection and increase the progression of the disease and mortality. Concerned patients may also discontinue anti-hypertensive medication. Therefore, patient education must emphasize the importance of consulting a physician if they have any concerns, and not interrupt diabetes or hypertension treatment on their own. To minimize the possibility of acquiring in-hospital infections in these immunocompromised patients, we set up a temporary outpatient clinic outside the main building with a video call assisted consulting system. We also established an outdoor drive-through pharmacy service to provide medication refills for chronic diseases. Self-monitoring of blood glucose (SMBG) can help clinicians to prescribe medication. If the patient is home quarantined, the results of SMBG can be uploaded to the hospital's platform via a mobile application such as Health2Sync or Rightest CARE, which will then remind the clinical caregiver to give advice to the patients through telemedicine. Although personal protective equipment such as a mask or alcohol-based hand sanitizers are relative available in Taiwan, some patients with diabetes still complain that they cannot buy enough alcohol wipes for sanitization before SMBG or insulin injections. In fact, soapy water is an effective alternative in this situation.4 Flu or pneumococci vaccinations have shown benefits including decreasing hospitalization and death in patients with diabetes.5 In the long term, diabetologists should do their best to encourage their patients to maintain good glycemic control and receive influenza and pneumococci vaccinations to ameliorate the risk of severe complications if they become infected with COVID-19. Social distancing is the mainstream of current public health policy. Diabetologists can achieve this by educating their patients with regards to adequate self-care techniques, maintaining good glycemic control, and timely vaccinations. All authors declare no conflict of interest.