Managing blood sugar in dexamethasone-treated COVID-19 patients: UK Guidance
UK: The UK National Diabetes COVID-19 Response Group has released new guidance on dexamethasone therapy in COVID‐19 patients. The guidance addresses the management of blood sugar levels in COVID-19 patients who are taking dexamethasone therapy.
The guidance was developed in response to The RECOVERY trial that found that dexamethasone can prevent be death in around 8 ventilated patients and about one in 25 patients who require oxygen. This has been considered as an important regimen in spite of the fact that the study is yet to attain peer-review publication. Low dose dexamethasone therapy as described in this study (6 mg daily for 10 daily) in effect is five to six-fold greater than the therapeutic glucocorticoid replacement dose. High doses of glucocorticoids can worsen hyperglycemia in diabetes patients, may unmask undiagnosed diabetes and, in those at risk of diabetes, may precipitate hyperglycemia and new-onset diabetes. Glucocorticoids are the commonest cause of diabetes people developing potentially life-threatening hyperglycaemic hyperosmolar state (HHS) in the hospital.
To prevent the harms, described above Joint British Diabetes Societies (JBDS) published guidelines that address inpatient management of steroid-induced hyperglycemia. However, these guidelines may not be appropriate for patients with severe COVID-19 infection receiving dexamethasone, given dexamethasone-induced impaired glucose metabolism, COVID-19 impaired insulin production, and COVID-19-induced insulin resistance.
This new guideline, published in the journal Diabetic Medicine specifically meant for people with severe COVID-19 infection commencing dexamethasone. The aim is to ensure that all patients commenced on dexamethasone whether or not they have diabetes, receive appropriate glucose surveillance and management of hyperglycemia should it occur.
Key recommendations include:
- The guideline recommends correction doses of rapid-acting analog insulin when capillary blood glucose > 12.0 mmol/l, with the dose calculated according to the patient's weight or in those already treated with insulin, on their total daily insulin dose.
- Unlike the previous guidance, this guideline does not recommend using the insulin correction ratios that some people with type 1 diabetes usually use as these may not be appropriate given the significant disturbance of glucose metabolism.
- To maintain glycaemic control NPH insulin is recommended which has an intermediate duration of action in preference to longer-acting insulin even though the metabolic effects of dexamethasone can persist for up to 36 h.
- NPH insulin given twice daily allows more flexibility in dose adjustment. The starting doses based on weight are slightly greater than those given in our previous guidance but as before, a reduced dose should be used in the frail, elderly and those with an eGFR of < 30 ml/min.
- If the patient is already on long-acting insulin or twice daily pre-mix insulin then it is recommended this be increased by 20%, but it is noted that this may actually require rapid escalation by 40% or more.
- Insulin resistance will fall when dexamethasone is stopped and so capillary blood sugar and insulin dose adjustment need careful monitoring to avoid hypoglycemia.
"We hope that these guidelines will be relevant for those managing COVID-19 patients treated with dexamethasone in the ward setting. Although not intended for critical care units where policies around blood sugar monitoring may differ and where insulin is likely to be given by intravenous infusion, the guidelines may be adapted for use in this setting," concluded the authors.
"Dexamethasone therapy in COVID‐19 patients: implications and guidance for the management of blood glucose in people with and without diabetes," is published in the journal Diabetic Medicine.
DOI: https://doi.org/10.1111/dme.14378
