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Diabetes care in the time of Covid 19 2021 Prof Vinod Patel
1. Diabetes Care in Primary and Secondary
Care in the time of COVID- 19
Professor Vinod Patel
FHEA FRCP MD MRCGP DRCOG PSc
Professor, Diabetes and Clinical Skills
Hon Consultant in Endocrinology and Diabetes
Warwick Medical School, George Eliot Hospital NHS Trust, Nuneaton
CD Diabetes NHS England and NHS Improvement (West Midlands)
2. Declaration of Interests
• I have worked with most of the large pharmaceutical industry groups over the years
with the majority of the work being in education of Healthcare Professionals in
Diabetes Care
• This includes Novo Nordisk, Eli Lily, MSD, BI, Sanofi, Napp, , Internis,Takeda and
AZ. I have been part of Advisory Board work on occasions.
• From these companies I would have received Conference Arrangements and
Lectures Fees.
• I am a trustee of the SAHF Charity (South Asian Health Foundation).
3. Life in the Time of COVID-
19
…Thoughts, Protection
Strategies and the Future
Educational Objectives- to facilitate you to
• Improve your care knowledge of the SARS-COV 2 Virus
• Be Informed of key statistics in relation to COVID-19
• Be safer in the Clinical Environment
• Be aware of the Clinical Care of the patient with Covid-19
• Be aware of the Clinical and Demographic Risk Factors for
Covid-19 deaths
• Discuss an interesting fact at dinner with your family
• Be better informed to protect you and your loved ones
• Reflect…..?
General Background
1. Introduction to the Virus
2. Global Prevalence and Deaths Data
Infection Control and Symptoms
1. Masks, PPE, “Space”
2. Main Symptoms
Risk Factors for Covid-19 Deaths
1. General Conditions and Age
2. Diabetes Focus: risk factors
Treatment of Covid-19
1. Why people die from Covid-19
2. General Treatments
3. Resuscitation
4. Dexamethasone, and Remdesivir
5. The First Vaccine given in UK
6. Vit D
Consultations, Communities
1. Virtual Consultations
2. Protection of Communities
Coping Strategies
1. Reducing Stress, Emotional Considerations
2. Final Remarks
Comments, Questions and Answers
4. • National Diabetes Audit (NDA) : main priorities for diabetes care
• COVID-19 and the Diabetes Patient: risks for death
• Role of SGLT-2- inhibitors: brief review of outcomes for patients
• Who to Prioritise in GP Care: Traffic-lights approach
• Care Planning: GP Systems and Care
• Final Remarks and Conclusions: Questions and Comments
Educational Objectives- to facilitate you to
• Be Informed of key statistics in relation to COVID-19
• Learn of COVID-19 risk factors for death
• Be informed of outcomes that can accrue from SGLT2-I Rx
• Become convinced of care planning in Diabetes Care
• Ask awkward questions
• Reflect on how you can change practice…..?
Diabetes Care in the time of COVID- 19
5. • National Diabetes Audit (NDA) and BSOL: main priorities for diabetes care
• COVID-19 and the Diabetes Patient: risks for death
• Role of SGLT-2- inhibitors: brief review of outcomes for patients
• Who to Prioritise in GP Care: Traffic-lights approach
• Care Planning: GP Systems and Care
• Final Remarks and Conclusions: Questions and Comments
Educational Objectives- to facilitate you to
• Be Informed of key statistics in relation to the local NDA
• Learn of COVID-19 risk factors for death
• Be informed of outcomes that can accrue from SGLT2-I Rx
• Become convinced of care planning in Diabetes Care
• Ask awkward questions
• Reflect on how you can change practice…..?
Diabetes Care in the time of COVID- 19
6. * All Three Treatment Targets NEW – HbA1c, Blood Pressure and Statins for Combined Prevention of CVD
7. 1.29 1.56 1.68
2.21
2.8
4.99
1.15 1.23
1.32 1.63
2.53
3.88
1.01
1.05
1.17
1.46 2.1
3.1
0.99 0.94 0.99 1.13
1.47 1.39
0
1
2
3
4
5
6
No Risk Factors 1 Risk Factor 2 Risk Factor 3 Risk Factor 4 Risk Factor 5 Risk Factor
Excess Mortality vs Risk Factors uncontrolled
Age < 55 Age 55-65 Age 65-80 80 plus
Risk Factor Control. Mortality and CVD Outcomes in
Patients with Type 2 Diabetes
Rawshani A et a. NEJM
2018;379:633-644.
5 Risk factors:
A: Current Smoker
B: BP ≥ 140/80
C: LDL ≥ 2.5 mmol/l
CKD: Albuminuria (Micro or Macro)
D: HbA1c > 53 mmol/mol (7%)
% increased risk
399 288 210 39
Similar Trends for:
• Excess MI
• Excess Stroke
• Excess Heart Failure
8. Urine ACR tests for diabetes patients are being completed
at low rates compared with other kidney function tests
1. NHS Digital. National Diabetes Audit. Report: Care Processes and Treatment Targets, January to December 2019. [Accessed
August 2020]. https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-audit/national-diabetes-
audit-quarterly-report-january-to-december-2019
2. NHS Scotland. Scottish Diabetes Survey 2018. June 2019. [Accessed August 2020]. https://www.diabetesinscotland.org.uk/wp-
content/uploads/2019/12/Scottish-Diabetes-Survey-2018.pdf
3. Nitsch D, et al, on behalf of the National CKD Audit and Quality Improvement Programme in Primary Care, First National CKD
Audit Report 2017. [Accessed August 2020]. www.hqip.org.uk/resource/national-chronic-kidney-disease-audit-national-report-
part-1/#.Xtzgipp7nOQ
*Diabetes type not specified. ACR: albumin/creatinine ratio; eGFR: estimated glomerular filtration rate; CKD: chronic kidney disease.
UK testing rates for serum creatinine, eGFR and urine albumin
88.4%
62.0%
0%
20%
40%
60%
80%
100%
National Diabetes Audit
(England only)
Patients
tested
(%)
Serum creatinine Urine albumin
Percentage of T2DM patients tested
(Jan – Dec 2019)1
Percentage of T2DM patients
tested in the previous
15 months (2018)2
*
38% of T2DM
patients in England and
haven’t had
a urine albumin
check within the last
12 – 15 months1,2
Although reported testing rates vary, these figures show urine albumin testing in the UK is poor
92.6%
85.9%
66.2%
53.9%
0%
20%
40%
60%
80%
100%
Scottish Diabetes Survey National CKD audit
(England & Wales)
eGFR Urine albumin
Percentage of diabetes patients*
tested annually (2016)3
9. • National Diabetes Audit (NDA) and BSOL: main priorities for diabetes care
• COVID-19 and the Diabetes Patient: risks for death
• Role of SGLT-2- inhibitors: brief review of outcomes for patients
• Who to Prioritise in GP Care: Traffic-lights approach
• Care Planning: GP Systems and Care
• Final Remarks and Conclusions: Questions and Comments
Educational Objectives- to facilitate you to
• Be Informed of key statistics in relation to the local NDA
• Learn of COVID-19 risk factors for death
• Be informed of outcomes that can accrue from SGLT2-I Rx
• Become convinced of care planning in Diabetes Care
• Ask awkward questions
• Reflect on how you can change practice…..?
Diabetes Care in the time of COVID- 19
10. Introduction to the Virus
• COVID-19 Pandemic: One of the most serious new health threats in the modern history
of humanity. Its propensity for rapid transmission has lead to 33 million diagnosed
cases and as of yesterday over a Million- 1 000 000 deaths globally within a few months
• COVID-19 is caused by SARS-CoV-2, a Beta-coronavirus closely related to the SARS virus.
Approx. 0.100 µm diameter
• Transmission: Respiratory, Naso-pharyngeal and Speech droplets by direct inoculation
via touching of fomites or breathing in such droplets. Asymptomatic carriage.
• Infectious dose ? Hundreds to thousands ? Chinese study 50000 particles. One mustard
seed, 1 mm across, 524 Billion virus capacity. 20 µm droplet: 4,189,000 minus dilution,
500 µm droplet: 65,400,000,000
Speech Droplets
“Stay Healthy”
Visualizing Speech-Generated Oral Fluid Droplets with Laser Light Scattering :
Anfinrud P et al, NEJM 2020
11. • SARS-COV-2 (2019) & SARS outbreak of 2003: Both coronavirus family, and both associated animals in "wet
markets.“
• Wet Markets: outdoor stalls are squeezed in narrow lanes - a stall selling caged chickens may abut a butcher
counter, where meat is chopped as nearby dogs are in cages
• Zoonotic Transmission/Infection: Wet markets put people and live and dead animals — dogs, chickens, pigs,
snakes, civets, dogs Easy for zoonotic diseases to jump from animals to humans
Aylin Woodward 2020 Business Insider Journalist
12. SARS-CoV-2 Infection of Airway Cells
Camille Ehre, Ph.D. NEJM 2020
• SARS-CoV-2: In a laboratory setting, was inoculated into human bronchial epithelial cells (biosafety level
3 facility)
• SEM: Cells were then examined 96 hours after infection with the use of scanning electron microscopy
• Panel A: shows an infected ciliated cell with strands of mucus attached to the cilia tips
• Panel B: shows the structure and density of SARS-CoV-2 virions produced by human airway epithelial
cells
• Virus production: was approximately 3×106 plaque-forming units per culture, a finding that is consistent
13. Global Causes of Death
Global: 7th Rank
Coronavirus Deaths*
Feb 6th 2021 2020
2,299,388 people
11 Months
*CNA Infographic 2020
14. Global Causes of Death
UK: 3rd Rank
Coronavirus Deaths
6th Feb 2021
111,264 people
11 Months
15.
16. To Mask or Not to Mask?
Face covering - ensure tight-fitting
17. Age Band % Total Deaths
0-19 18 0.06%
20-39 196 0.7%
40-59 2173 7.8%
60-79 10556 38.1%
80+ 14763 53.3%
0-19 20-39 40-59 60-79 80+
0-19 1.0 10.8 120.7 586.4 820.2
20-39 0.1 1.0 11.1 53.9 75.3
40-59 0.01 0.09 1.0 4.86 6.79
60-79 0.002 0.02 0.21 1.0 1.40
80+ 0.001 0.013 0.147 0.715 1.0
Age and COVID-19 Mortality Matrix
9th June 2020 NHS Data
Comparative Risks
Total Deaths: 27706
0-19
20-39
40-59
60-79
80+
All
18. Type 1 and Type 2 Diabetes and COVID-19 related mortality in England:
a whole population study
Emma Barron , Chiraj Bakhai, Partha Kar, Andy Weaver, Dominique Bradley, Hassan Ismail, Peter Knighton, Naomi
Holman, Kamlesh Khunti, Naveed Sattar, Nick Wareham, Bob Young, Jonathan Valabhji
NHS England Website accessed 20/5/2020
England Data
No Diabetes
Type 1 DM
Type 2 DM
Other DM
No Diabetes 94.84%
Type 1 DM 0.43%
Type 2 DM 4.66%
Other DM 0.07%
COVID-19 Deaths
People with Diabetes in England-
5.16%
19. Type 1 and Type 2 Diabetes and COVID-19 related mortality in England:
a whole population study
Emma Barron , Chiraj Bakhai, Partha Kar, Andy Weaver, Dominique Bradley, Hassan Ismail, Peter Knighton, Naomi
Holman, Kamlesh Khunti, Naveed Sattar, Nick Wareham, Bob Young, Jonathan Valabhji
NHS England Website accessed 20/5/2020
COVID-19 Deaths
No Diabetes
Type 1 DM
Type 2 DM
Other DM
No Diabetes 66.8%
Type 1 DM 1.5%
Type 2 DM 31.4%
Other DM 0.3%
One Third of COVID-19 Deaths in Hospital in
People with Diabetes- 33.2%
People with Diabetes in England-
5.16%
20. • People with diabetes should be reminded that diabetes increases risk of
many infections, and that may include COVID-19
• Maintaining good glucose control, a healthy diet and regular exercise are
important for all
• Current UK advice is to continue usual glucose lowering drugs, and aim
to optimise glucose control
• Antihypertensives (including ACEi’s and ARBs) and lipid lowering drugs
should also be continued
What practical advice should we give to the majority of people
with type 2 diabetes (who are well)?
https: / /www .diabetesonthenet .com /journals /issue /607 /article-details /glance-factsheet-covid-19-and-diabetes-dpc
21. • Type 1 Diabetes and Type 2 Diabetes: People with both types of diabetes
are more likely to have the serious outcomes from coronavirus infection
• NHS England Diabetes and Coronavirus Studies: In May 2020, two studies
were published which showed that people with diabetes with coronavirus
were at higher risk of dying. This result only applies to those people with
diabetes with such severe coronavirus disease that admission to hospital
was essential.
• Highest Risks for death: This was in the elderly, often with other
conditions such as heart disease, stroke or kidney disease. There were
very few deaths under the age of 40.
Patient Information on the Diabetes and COVID-19 Studies
Type 1 and Type 2 Diabetes and COVID-19 related mortality in England: a whole population study
Emma Barron , Chiraj Bakhai, Partha Kar, Andy Weaver, Dominique Bradley, Hassan Ismail, Peter Knighton,
Naomi Holman, Kamlesh Khunti, Naveed Sattar, Nick Wareham, Bob Young, Jonathan Valabhji .
NHS England Website accessed 20/5/2020
Type 1 and Type 2 Diabetes and COVID-19 related mortality in England: a cohort study in people with
diabetes. Naomi Holman, Peter Knighton, Partha Kar, Jackie O’Keefe, Matt Curley, Andy Weaver, Emma
Barron , Chiraj Bakhai, Kamlesh Khunti, Nick Wareham, Naveed Sattar, Bob Young, Jonathan Valabhji : NHS
England Website Accessed May 2020
22. • Community Coronavirus Infections: Current evidence suggests that
people with diabetes are no more likely to catch coronavirus infection
than those without diabetes. However, if there is coronavirus infection
requiring hospital admission then the outcome is more likely to be serious
than in people without diabetes.
• Mild and Moderate coronavirus infection: It is clear that many hundreds
of people with diabetes have had the infection the community and made a
good recovery from there mild to moderate illness.
• Risk Stratification: could help identify diabetes patients, within a clinical
service, that need most urgent intervention where services are stretched
and working in different ways due to the COVID-19 Pandemic
• You and your Healthcare Professionals could use the information from
the studies to help identify any risk factors that you have may have that
could lead an increased chance of a more serious outcome from
coronavirus infection. Some of these could be improved to your potential
benefit- such as an improvement in glycaemic control
Patient Information on the Diabetes and COVID-19 Studies
23. • The findings from the studies could be integrated into a Care Plan for you using the
following main points:
– Good diabetes control is important with a HbA1c target that is individualised to you.
This would take into account not just the current coronavirus pandemic with prevention
of other complications.
– Weight control: very high BMI and lower BMI were associated with the most serious
outcomes of coronavirus infection. A personal, achievable target can be discussed if you
want. Physical activity and a healthy diet remain important in this regard.
– Cardiovascular disease prevention and management: Heart attacks, strokes and Heart
Failure were all associated with poorer outcomes with coronavirus infection.
Management and prevention of these conditions through lifestyle measures (especially
not smoking), Blood Pressure Control, cholesterol-lowering, foot care are all essential.
• The following tables could be used to inform a discussion on the risk factors for a
more serious outcome associated with coronavirus infection specific to your type
of diabetes and other factors such as age, ethnicity, HbA1c, weight and duration of
diabetes.
How these studies can help manage your diabetes
24. Groups at higher risk to develop severe illness from
COVID-19
BMI, body mass index
CDC: https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/people-at-higher-risk.html Accessed: June 2020; Public Health UK:
https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-
and-protecting-older-people-and-vulnerable-adults Accessed: June 2020.
People aged 70
years and older
People who live in a
nursing home or
long-term care facility
Other high-risk conditions could include:
• People of any age with severe obesity (BMI >40 kg/m2) or certain underlying medical conditions,
particularly if not well controlled, such as those with diabetes, renal failure, or liver disease
might also be at risk
• People with chronic lung disease or moderate to severe asthma
• People who have serious heart conditions
• People who are immunocompromised including cancer treatment
• Pregnant women should be monitored since they are known to be at risk with severe viral illness
25. The most frequent comorbidities in COVID-19
Yang J, et al. Int J Infect Dis. 2020;94:91-95.
A meta analysis of 7 studies with 1,576 COVID-19 patients showed the most
prevalent comorbidity:
Hypertension
21.1%
Diabetes
9.7%
Cardiovascular
diseases
8.4%
Respiratory
system disease
1.5%
26. Type 1 and Type 2 Diabetes and COVID-19 related mortality in England:
a whole population study
Emma Barron , Chiraj Bakhai, Partha Kar, Andy Weaver, Dominique Bradley, Hassan Ismail, Peter Knighton, Naomi
Holman, Kamlesh Khunti, Naveed Sattar, Nick Wareham, Bob Young, Jonathan Valabhji
NHS England Website accessed 20/5/2020
COVID-19 Deaths
No Diabetes
Type 1 DM
Type 2 DM
Other DM
No Diabetes 66.8%
Type 1 DM 1.5%
Type 2 DM 31.4%
Other DM 0.3%
One Third of COVID-19 Deaths in Hospital in
People with Diabetes- 33.2%
People with Diabetes in England-
5.16%
27. COVID-19 and Diabetes
T1D, type 1 diabetes; T2D, type 2 diabetes
ADA: https://www.diabetes.org/coronavirus-covid-19 Accessed: June 2020; CDC: https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/people-at-higher-risk.html Accessed: June 2020.
NHS England – Naomi Holman, et al. Type 1 and Type 2 diabetes and COVID-19 related mortality in England: a cohort study in people with diabetes. https://www.england.nhs.uk/wp-
content/uploads/2020/05/Valabhji-COVID-19-and-Diabetes-Paper-2-Full-Manuscript.pdf Accessed: June 2020.
NHS England - Barron E, et al. Type 1 and Type 2 diabetes and COVID-19 related mortality in England: a whole population study.
https://www.england.nhs.uk/wp-content/uploads/2020/05/valabhji-COVID-19-and-Diabetes-Paper-1.pdf Accessed: June 2020.
People with diabetes are not more
likely to get COVID-19 than the
general population.
=
Diabetes is one of the
high risk groups for developing
severe
illness from COVID-19.
People with type 1 diabetes have an
increased risk of developing
diabetic ketoacidosis if infected
with viral or bacterial infections.
28. NHS England Data – Risk factors for Mortality (1)
COVID-19 and Diabetes
T1D, Type 1 Diabetes; T2D, Type 2 Diabetes; BAME, Black, Asian and Minority Ethnic
NHS England - Barron E, et al. Type 1 and Type 2 diabetes and COVID-19 related mortality in England: a whole population study. https://www.england.nhs.uk/wp-content/uploads/2020/05/valabhji-
COVID-19-and-Diabetes-Paper-1.pdf Accessed: June 2020.
NHS England – Naomi Holman, et al. Type 1 and Type 2 diabetes and COVID-19 related mortality in England: a cohort study in people with diabetes. https://www.england.nhs.uk/wp-
content/uploads/2020/05/Valabhji-COVID-19-and-Diabetes-Paper-2-Full-Manuscript.pdf Accessed: June 2020.
The strongest risk factor for mortality with
COVID-19 is age.
People with T1D and T2D, men,
BAME ethnicity or living in more
deprived circumstances are at a
higher risk of mortality.
The risk of mortality remains low under
the age of 40.
The death rates of people with diabetes
doubled during the early phase of the
pandemic.
29. NHS England Data – Risk factors for Mortality (2)
COVID-19 and Diabetes
T1D, Type 1 Diabetes; T2D, Type 2 Diabetes; BAME, Black, Asian and Minority Ethnic
NHS England - Barron E, et al. Type 1 and Type 2 diabetes and COVID-19 related mortality in England: a whole population study. https://www.england.nhs.uk/wp-content/uploads/2020/05/valabhji-
COVID-19-and-Diabetes-Paper-1.pdf Accessed: June 2020.
NHS England – Naomi Holman, et al. Type 1 and Type 2 diabetes and COVID-19 related mortality in England: a cohort study in people with diabetes. https://www.england.nhs.uk/wp-
content/uploads/2020/05/Valabhji-COVID-19-and-Diabetes-Paper-2-Full-Manuscript.pdf Accessed: June 2020.
In both T1D and T2D, those with
pre-existing kidney disease, heart
failure and previous stroke are at a
higher risk of mortality.
Hyperglycaemia and obesity are
linked to increased risk of
mortality.
Tight glycaemic control and low BMI
are also risk factors of mortality with
COVID-19.
30. People with Diabetes Mellitus may
have innate immunity defects
Increased risk of severe infection
because of increased cytokines
Ma and Holt. Diabet Med. 2020. doi: 10.1111/dme.14300.
Why are patients with diabetes a high risk group for developing severe illness?
• Linked to hyperglycaemia
• Both acute and chronic effects
31. Only statistically significant data is colour coded. Amber less than 50% increase in HR, Red > 50%
increase in HR, Current Smoking was protective- reasons not clear.
NHS England: COVID-19 Mortality Studies Type 2 Diabetes
HCP to consider using tick marks, to individualise to patient*
Type 2 Diabetes Lower Risk Higher Risk Your Lower
Risks*
Your Higher
Risks*
Gender Female, 1.0 Male 1.59
Ethnicity White, 1.0 Black 1.63 Asian 1.09* Mixed 1.3
Age yrs 60-69, 1.0 70-79, 1.92 80+, 4.39
Duration 3-4, 1.0 15-19, 1.14 20+, 1.17
IMD* IMD 5, 1.0 3, 1.07 2, 1.27 1, 1.45
Previous Stroke No Stroke, 1.0 1.95
Previous HF No HF, 1.0 2.05
HbAc 49-58
1.0
54-58
1.05
59-74
1.23
75-85
1.37
86+
1.62
BMI 1 25-29.9
1.0
30-34.9
1.04
35-39.9
1.16
40+
1.64
BMI 2 25-29.9
1.0
20-24.9
1.31
<20
2.26
eGFR 60
1.0
45-59
1.37
30-44
1.75
15-29
2.24
<15
4.83
Based on Data from Holman N et al 2020 NHS England
32. Only statistically significant data is colour coded. Amber less than 50% increase in HR, Red > 50% increase in HR
NHS England: COVID-19 Mortality Studies Type 1 Diabetes
HCP to consider using tick marks, to individualise to patient*
Type 1 Diabetes Lower Risk Higher Risk Your Lower
Risks*
Your Higher
Risks*
Gender Female, 1.0 Male 1.64
Ethnicity White, 1.0 Black 1.79 Asian 1.68 Other 2.0
Age yrs 60-69, 1.0 70-79, 1.84 80+, 4.63
IMD* IMD 5, 1.0 3, 1.79 2, 1.53 1, 1.79
Previous Stroke No Stroke, 1.0 2.14
Previous HF No HF, 1.0 1.82
HbAc 49-58, 1.0 86+, 2.19
BMI 1 25-29.9
1.0
30-34.9
1.5
35-39.9
1.70
40+
2.15
BMI 2 25-29.9
1.0
20-24.9
1.38
<20
2.11
eGFR 60+, 1.0 45-59
1.92
30-44
2.16
15-29
2.98
<15
6.85
Entirely Based on Data from Holman N et al 2020 NHS England
33. • Most people (80%) will have mild disease and
can be managed at home.
• Usual sick day rules apply – stop SGLT2i and
metformin if unwell and not eating or drinking
normally, other medication (eg SUs) may
need adjustment
• Never stop insulin
• Monitor glucose frequently (every 2-4 hours)
– ketone testing needed for type 1 diabetes
https://www.diabetesonthenet.com/journals/issue/607/article-details/glance-factsheet-covid-19-and-diabetes-
Please consult individual product SmPCs for full product information
Specific considerations for primary care management of people with
COVID-19 and suspected COVID-19 infection
34. Diabetes Control:
UKPDS: 1% ( ~ 10mmol/mol) decrease in HbA1c
is associated with a reduction in complications by….
Stratton IM, et al. BMJ 2000; 321: 405–12.
43
%
37
%
21
%
14
%
12
%
HbA
1C
1%
* p<0.0001
** p=0.035 Stroke**
Microvascular
complications e.g.
kidney disease and
blindness *
Amputation or fatal
peripheral blood vessel
disease*
Deaths related to
diabetes*
Heart attack*
35. Adjusted Hazard Ratios: HbA1c and COVID-Death
Type 1
Diabetes
COVID-19
Deaths
Type 2
Diabetes
COVID-19
Deaths
HbA1c
Mmol/mol
<48 18010
6.8%
1.22 726600
25.1%
1.11
49-53** 21610
8.2%
1.0 594270
20.6%
1.0
54-58 25250
9.5%
0.73 367365
12.7%
1.05
59-74 77550
29.3%
1.15 553840
19.2%
1.23
75-85 30235
11.4%
1.31 157685
5.5%
1.37
86+ 31380
11.8%
2.19 175640
6.1%
1.62
Missing 61055
23.0%
1.6 313815
10.9%
1.57
Type 1 and Type 2 Diabetes and COVID-19 related mortality in England:
a cohort study in people with diabetes
• Data are adjusted HRs for diabetes type specific Cox’s proportional hazards multivariate survival model
• Only statistically significant data is colour coded. Amber up to 50% increase in HR, Red > 50% increase in HR, Blue
lower risk. ** indicate data compared to as reference:
36. What is the Mechanism driving this increased risk?
We don’t know for sure
• Diabetes and General Pneumonia: Type 1 DM risk 2.98 higher, Type 2 DM 1.58
higher
• Immune system effect?: T-cells dysfunction, B-cell dysfunction
• Glycation of Proteins: Haemoglobin glycation- HbA1c- is convenient to
measure. All proteins glycate at the lysine, arginine and N-terminal of proteins
• Glycation-relation dysfunction? Leading to disease unfolding more seriously
such as virus uptake receptor (ACE 2)
Carey IM et al. Diabetes Care
2018;41:513-521
38. “The Perfect Storm”
Age, Male, Obesity and
Metabolic inflammation
NON-2020-2954 Nov 2020
Differentiating viral COVID-19 pneumonia from bacterial pneumonia
•It is difficult to determine whether pneumonia has a COVID-19 viral cause or a bacterial
cause (either primary or secondary to COVID-19) in primary care, particularly during
remote consultations. However, as COVID-19 becomes more prevalent in the community,
people presenting with pneumonia symptoms are more likely to have a COVID-19 viral
pneumonia than a community-acquired bacterial pneumonia.
•COVID-19 viral pneumonia may be more likely if the person:
• Presents with a history of typical COVID-19 symptoms for about a week.
• Has severe muscle pain (myalgia).
• Has loss of sense of smell (anosmia).
• Is breathless but has no pleuritic pain.
• Has a history of exposure to known or suspected COVID-19, such as a
household or workplace contact.
•A bacterial cause of pneumonia may be more likely if the person:
• Becomes rapidly unwell after only a few days of symptoms.
• Does not have a history of typical COVID-19 symptoms.
• Has pleuritic pain.
• Has purulent sputum.
40. • National Diabetes Audit (NDA) and BSOL: main priorities for diabetes care
• COVID-19 and the Diabetes Patient: risks for death
• Role of SGLT-2- inhibitors: brief review of outcomes for patients
• Who to Prioritise in GP Care: Traffic-lights approach
• Care Planning: GP Systems and Care
• Final Remarks and Conclusions: Questions and Comments
Educational Objectives- to facilitate you to
• Be Informed of key statistics in relation to the local NDA
• Learn of COVID-19 risk factors for death
• Be informed of outcomes that can accrue from SGLT2-I Rx
• Become convinced of care planning in Diabetes Care
• Ask awkward questions
• Reflect on how you can change practice…..?
Diabetes Care in the time of COVID- 19
41. ABCD Recovery Guidance (June 2020)
Red Amber Green
Recommended Review Date Review all “Red” patients within 3
months
Review all “Amber” patients by
31.12.2020
Inform patients in this category
that they are unlikely to be seen
before early 2021.
Provide clear advice on where and
how to contact the team for
emergency support if things change
Metabolic Control
Alternative Measures
BP (mm of Hg)
Hba1c 86 mmol/mol (10%)
<30% time in range
BP>160/100
69-86 mmol/mol (8.5- 10%)
30-50% time in range
BP 140-160 /100 on suboptimal
medication
<64 mmol/mol (8.0%)
>50% time in range
BP <140/80
Hypoglycaemia Risk Complete loss of awareness (e.g.
Gold score 6-7)
Severe Hypos needing 3rd Party
assistance in last 12 months
Impaired awareness of
hypoglycaemia (e.g. Gold score 4-
5)
HbA1c <48 mmol/l on insulin or
sulfonylureas. With known frailty,
cognitive impairment or eGFR
<30ml/min
>20% time below 4mmol/l
Normal awareness of
hypoglycaemia
https://abcd.care/sites/abcd.care/files/site_uploads/Resources/COVID-19/ABCD-Recovery-Guidance-2020-06-23.pdf
42. ABCD Recovery Guidance (June 2020)
Red Amber Green
Renal Function Known CKD level 4 or more
(eGFR <30ml/min)
Known to diabetes renal service
(optimise care and avoid
duplication)
Rapidly declining renal function
(eGFR reduction >15
ml/min/year)
Known CKD 3b (eGFR
<45ml/min)
or
Progressive albuminuria
ACR >30 mg/mol
Risk of admission Admission in the last 12 months
with
• Unstable glucose (DKA/HHS
or hypoglycaemia)
• Cardiovascular ds
• Cerebrovascular ds
Admission with unrelated
condition where hypoglycaemia
was a major factor
Those with frailty/cognitive
impairment needing additional
support from their diabetes
teams.
https://abcd.care/sites/abcd.care/files/site_uploads/Resources/COVID-19/ABCD-Recovery-Guidance-2020-06-23.pdf
43. ABCD Recovery Guidance (June 2020)
Red Amber Green
Diabetes Foot status Known active diabetes foot
disease
Known high risk foot disease not
known to podiatry services.
No known diabetes foot disease
Other factors Planning pregnancy in next 6
months
Young patient (age <40yrs) with
T1D or T2D with known early
complications
https://abcd.care/sites/abcd.care/files/site_uploads/Resources/COVID-19/ABCD-Recovery-Guidance-2020-06-23.pdf
Wales recommendations for Triage of people with diabetes post COVID Aug 2020 includes above and
additional points:
Red:
Eating disorders, serious mental health issues, Newly diagnosed T1 and T2 diagnosis, Vulnerable groups such as
the homeless and those needing glucose optimisation pre –surgery
Amber:
Patients 16-25yrs, Patients with no diabetes review in last 18months, People with a body mass index greater
than 30kg/m2 and People in BAME groups.
44.
45. The COVID-2019 Vaccine- A Holy Grail ?
NB: Deal with AstraZeneca, shifts some of the risks involved in the roll-out
of a vaccine to taxpayers in UK and EU
WHO Update: September 2020
• ….Racing to find a vaccine. Vaccines save millions of lives each year.
Vaccines work by training and preparing the immune system to
recognize and fight off viruses and bacteria. The body is then
immediately ready to destroy them, preventing illness.
• Vaccines prevent 2 to 3 million deaths per every year - diphtheria,
tetanus, pertussis, influenza and measles. There are now vaccines to
prevent more than 20 life-threatening diseases
• Currently over 169 COVID-19 vaccine candidates under development,
with 26 of these in the human trial phase
• WHO will facilitate equitable access and distribution of these vaccines
to protect people in all countries. People most at risk will be prioritized.
47. The COVID-2019 Vaccine-
First Persons given vaccine outside of a trial- in Coventry!
• Pfizer/BioNTech Covid vaccine: First people in the
world, outside of clinical trials, received the in Coventry
at UHCW
• "V Day“: 8th of December 2020, dubbed "V Day" by
Health Secretary Matt Hancock is a historical date
• Margaret Keenan : at 6.31am, given vaccine by Nurse
May Parsons
Margaret, who will be 91 next week, said:
“I feel so privileged to be the first person vaccinated against
Covid-19.
"It’s the best early birthday present I could wish for because it
means I can finally look forward to spending time with my family
and friends in the New Year after being on my own for most of the
year.”
She added: “I don’t know how I feel, it’s just so strange and so
wonderful really”
Bill: The next Midlander to make history was William
Shakespeare from Warwickshire, aged 81.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70. The ChAdOx1 nCOV-19 Vaccine against SARD: an
interim analysis from 4 RCT in Brazil, South Africa
and the UK
Professor Vinod Patel
Psc (Hons) FHEA FRCP MD MRCGP PSc
Professor, Diabetes and Clinical Skills
Warwick Medical School
Hon Consultant in Endocrinology and Diabetes
George Eliot Hospital NHS Trust, Nuneaton
71. Safety and efficacy of the
ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2:
an interim analysis of four randomised controlled trials
in Brazil, South Africa, and the UK
Voysey M et al. Lancet 2021;397:99-111
Oxford University has entered into a partnership with AstraZeneca for further development of ChAdOx1 nCoV-19. SCG is
co-founder ofVaccitech (collaborators in the early development of this vaccine candidate) and named as an inventor on a
patent covering use of ChAdOx1-vectored vaccines and a patent application covering this SARS-CoV-2 vaccine
(PCT/GB2012/000467).
72. The COVID-2019 Vaccine-
First Person ever given ChAdOx1 nCOV-19 Vaccine in
Oxford The first person in the UK has received AstraZeneca
and Oxford University’s COVID-19 vaccine, less than a
week after the vaccine was approved by the
Medicines and Healthcare products Regulatory
Agency (MHRA).
Brian Pinker, an 82-year-old dialysis patient, received
the vaccine at 7:30am on 4th January 2021 at the
Churchill Hospital, Oxford University Hospitals NHS
Foundation Trust.
Over half a million doses – approximately 530,000 – of the
vaccine will be made available on the first day. The
vaccine doses will be administered 12 weeks apart, rather
than the original 21-day gap, as the UK government aims
to speed up its vaccination roll-out plans.
The aim of the 12-week gap is to allow more people to
receive their first dose, with the UK’s chief medical officers
maintaining that “the great majority of the initial protection
from clinical disease is after the first dose of vaccine”.
73. Safety and efficacy of the
ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2:
Introduction
• SARS-CoV-2 Pandemic has led to widespread impact on health, including substantial mortality among older adults
and those with pre-existing health conditions
• Vaccines could play an important role in increasing population immunity, preventing severe disease, and reducing
the ongoing health crisis. Currently, 48 vaccines are under clinical evaluation (11 Phase 3)
• ChAdOx1 nCoV-19 vaccine (AZD1222), consists of a replication-deficient chimpanzee adenoviral vector ChAdOx1
containing the SARS-CoV-2 structural surface glycoprotein antigen (spike protein; nCoV-19) gene.
• Phase 1 UK clinical trial in the UK (COV001) started on April 23, 2020, three RCT initiated across the UK (COV002),
Brazil (COV003), and South Africa (COV005). Kenya is not reported here.
• Immunogenicity results from the phase 1/2 UK study, COV001, in 1077 healthy adults aged 18–55 years, and a phase
2 cohort in COV002 in older adults (≥56 years) show an acceptable safety profile for the vaccine with induction of
binding and neutralising antibodies as well as generation of interferon-γ enzyme-linked immunospot responses, with
higher antibody titres after a second dose of vaccine.
• Exclusion criteria were reduced for phase 3 trials, so that older adults and individuals with a range of comorbidities
were also enrolled.
All studies have completed enrolment of their respective efficacy cohorts and are in the follow-up phase. Paediatric
studies have not yet been initiated.
74. Safety and efficacy of the
ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2:
Background
• A safe and efficacious vaccine vs SARS-CoV-2, could contribute to the control of the COVID-19 pandemic.
Methods
• Data from 4 ongoing blinded RCT from UK, Brazil, and South Africa
• Participants aged 18 years and older were randomly assigned (1:1) to ChAdOx1 nCoV-19 vaccine or control
(meningococcal group A, C, W, and Y conjugate vaccine or saline)
• ChAdOx1 nCoV-19 group had 2 doses containing 5 × 1010 viral particles. A UK subset received a half dose as their first
dose (low dose) and a standard dose as their second dose (LD/SD cohort)
• Primary efficacy analysis included symptomatic COVID-19 in seronegative participants with a nucleic acid
amplification test-positive swab more than 14 days after a second dose of vaccine
• Participants were analysed according to treatment received, with data cutoff on Nov 4, 2020
• Vaccine efficacy was calculated as 1 - relative risk derived from a robust Poisson regression model adjusted for age.
• Studies are registered at ISRCTN89951424 and ClinicalTrials.gov, NCT04324606, NCT04400838, and NCT04444674.
75. Safety and efficacy of the
ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2:
Findings
• From April 23 to Nov 4, 2020, 23 848 participants were enrolled and 11 636 participants (7548 UK, 4088 Brazil) were
included in the interim primary efficacy analysis.
• Participants with two standard doses, vaccine efficacy was:
• 62·1% (95% CI 41·0–75·7)
• Coronavirus status: 27 [0·6%] of 4440 in the ChAdOx1 nCoV-19 group vs71 [1·6%] of 4455 in the control group
• Participants who received a low dose followed by a standard dose, efficacy was:
• 90·0% (67·4–97·0)
• Coronavirus status: 3 [0·2%] of 1367 vs 30 [2·2%] of 1374; p=0·010)
• Overall vaccine efficacy across both groups was:
• 70·4% (95·8% CI 54·8–80·6)
• Coronavirus status: 30 [0·5%] of 5807 vs 101 [1·7%] of 5829)
• Hospitalisation: From 21 days after the first dose, there were 10 cases hospitalised for COVID-19, all in the control
arm; two were classified as severe COVID-19, including one death
• Safety: 74 341 person-months of safety follow-up (median 3·4 months, IQR 1·3–4·8)
• 175 severe adverse events in 168 participants, 84 events in ChAdOx1 nCoV-19 group, 91 in the control group.
• 3 events possibly related to a vaccine: 1 in ChAdOx1 nCoV-19 group, 1 in control group, 1 remains masked
Interpretation
ChAdOx1 nCoV-19 has an acceptable safety profile and has been found to be efficacious against symptomatic COVID-19
in this interim analysis of ongoing clinical trials.
76. Safety and efficacy of the
ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2:
FigureKaplan-Meier cumulative incidence of primary
symptomatic, NAAT-positive COVID-19
Cumulative incidence of symptomatic COVID-19 after two doses (left) or after first standard dose in participants receiving only standard-dose vaccines
(right). Grey shaded areas show the exclusion period after each dose in which cases were excluded from the analysis. Blue and red shaded areas show 95%
CIs. LD/SD=low-dose prime plus standard-dose boost. MenACWY=meningococcal group A, C, W, and Y conjugate vaccine. NAAT=nucleic acid amplification
test. SD/SD=two standard-dose vaccines given.
77. Pathway for Person with Diabetes in the
COVID-19 Follow-up Clinic
Leicester Diabetes Centre
Professor Kamlesh Khunti and
Professor Melanie Davies and Team
82. Quick Guide to Glucose-lowering
Agents (excluding Insulin)
Leicester Diabetes Centre
Professor Kamlesh Khunti and
Professor Melanie Davies and Team
83. Quick Guide to Glucose-lowering
Agents (excluding Insulin)
Leicester Diabetes Centre
Professor Kamlesh Khunti and
Professor Melanie Davies and Team
84. Integrated Care Pathway for People with
Diabetes in the Time of Covid-19
Leicester Diabetes Centre
Professor Kamlesh Khunti and
Professor Melanie Davies and Team
99. • Primary Care Referral: All dependent
of level of resources and expertise
• Early Referral
• Referred may not be required
• Referral normally not needed
• Secondary Care Referral: All
dependent on diabetes care expertise
• Early Referral
• Referred may not be required
• Referral normally not needed
Diabetes Care
Referral Criteria
A Safety “Checklist”, Patient-Centred, Multi-
Professional, Evidence-based Approach
100. C+V Guidance for Primary Care Diabetes Prioritisation and Remote Reviews Dr Sarah Davies May 2020
Patient Groups
Patients where benefit of a F2F visit
outweighs risk
Consider single visit to surgery for practical
assessments: HBA1c, U+Es, ACR, BP, weight, foot check
Remote consultation with results
Remote Video or Telephone Consultation Checklist
Check available results:
• Current or previous HBA1c / home glucose readings
• Weight changes and BP
• U&Es and ACR
Review symptoms and lifestyle:
• Alert flags: thirst, lethargy, recurrent infections, foot issues, vision,
neuropathic symptoms
• Signpost lifestyle resources / Ref Dieticians (virtual consults/education)
• Remember mental health
Medication review:
• Compliance
• Side effects
• Awareness of sick day rules
Complications:
• Feet: Home Foot assessment – Diabetes UK Touch your toes test, if
concerns convert to video consult. Referral to podiatry if appropriate
• Eyes: review last retinopathy screening, signpost if any new issues
Signpost or provide written resources via email or post (links below):
• Sick day rules for patients
• Diabetes UK Website
• Diabetes UK Information Prescriptions
• Pocket Medic Videos
• Starting injectables videos
Plan next review date and safety net
Referrals
For a response within 48hrs email the Community Team (GPwSIs, DSNs)
Alternatively contact your Community Diabetes Consultant Team
Podiatry: Walk-In Clinic CRI Tues/Fri 9-11 or Hot Tel. for urgent advice XXXXXXXXXX
Requires Face2Face
(F2F) Review
Suspected new Type 1 diabetes
Unwell patient with diabetes,
possible ketosis
Needs Review
New diagnosis Type 2 diabetes
New/worsening foot issue
HBa1c over personal target (now or at
previous check), prioritise those >64mmol/mol
Recent therapy change
Declining renal function
Needs to commence injectable therapy
Safe to Defer Review
for 6 months
Well controlled, HBA1c to target
in the last year
Engaged with treatment
Needs Review
Patients where F2F visit can be
avoided - remote review
Consider using a pre assessment questionnaire
to gather information first (example available)
Inform the patient of the details of their planned
remote review.
Ask them to prepare by undertaking home
assessments if possible for:
• Blood glucose monitoring (if suitable)
• BP checks
• Weight recording
• Self foot assessment
Drop in/send in urine sample for ACR
Patients where benefit of a F2F visit
outweighs risk
Consider single visit to surgery for practical
assessments: HBA1c, U+Es, ACR, BP, weight, foot
check
Follow Up by remote consultation with results
Needs Review - options
101. Morbidity of hypoglycaemia in diabetes
Blackouts, Seizures,
Coma, Death
Cognitive dysfunction
Psychological effects
Myocardial ischaemia (angina and infarction)
Cardiac arrhythmia
Abnormal prolonged QTc
Sudden death
Falls, Accidents
eg driving
fractures, dislocations
ABC of Diabetes.
Holt and Kumar
2015. BMJ Books
Brain Musculoskeletal
Cardiovascular
102. PICO Analysis of the Dexamethasone Study
Patients: Hospitalised, clinically suspected or laboratory confirmed SARS-CoV-2 infection.
2104 patients were randomised to dexamethasone vs 4321 usual care.
Intervention: Dexamethasone 6mg od. Either oral or IV- single dose. For 10 Days or until
discharge if sooner.
Comparison: Usual current Standard of Care in UK Hospital setting
Outcomes: June, recruitment to the Dex. Halted, results clear evidence of clinical
benefits. Overall, with usual care alone, 28-day mortality highest in ventilation (41%),
intermediate in oxygen only (25%), and lowest in no respiratory intervention (13%).
Patients treated with Dexamethasone:
• Overall Dexamethasone reduced deaths by 17%: From 24.6% to 21.6%
• In ventilated patients: Deaths reduced by 35%, Rate Ratio-RR- 0.65 [95% CI 0.48-0.88, p <0.001)
• Oxygen Therapy no Ventilation: Deaths reduced by 20%, RR 0.80 [95% CI 0.67-0.96, =0.0021)
• No benefit in “did not require respiratory support” RR 1.22 [95% CI 0.86-1.75]; p=0.14).
Number Needed to Treat (NNT): Based on these results, 1 death would be prevented by
treatment of around 8 ventilated patients or around 25 patients requiring oxygen alone.
Dexamethasone in COVID-19:
Clear Benefit in Hospitalised Patients on Oxygen Therapies
103. COVID: Diabetes
Dexamethasone in COVID-19 Patients:
Implications and Guidance for the Management of Blood Glucose
in People with and without Diabetes
All Slides cut from Original PDF Document
104. COVID: Diabetes
Dexamethasone in COVID-19 Patients:
Implications and Guidance for the Management of Blood Glucose
in People with and without Diabetes
105. COVID: Diabetes
Dexamethasone in COVID-19 Patients:
Implications and Guidance for the Management of Blood Glucose
in People with and without Diabetes
106. COVID: Diabetes
Dexamethasone in COVID-19 Patients:
Implications and Guidance for the Management of Blood Glucose
in People with and without Diabetes
107. COVID: Diabetes
Dexamethasone in COVID-19 Patients:
Implications and Guidance for the Management of Blood Glucose
in People with and without Diabetes
108. COVID: Diabetes
Dexamethasone in COVID-19 Patients:
Implications and Guidance for the Management of Blood Glucose
in People with and without Diabetes
109. COVID: Diabetes
Dexamethasone in COVID-19 Patients:
Implications and Guidance for the Management of Blood Glucose
in People with and without Diabetes
110. COVID: Diabetes
Dexamethasone in COVID-19 Patients:
Implications and Guidance for the Management of Blood Glucose
in People with and without Diabetes
111. COVID: Diabetes
Dexamethasone in COVID-19 Patients:
Implications and Guidance for the Management of Blood Glucose
in People with and without Diabetes
112. • National Diabetes Audit (NDA) and BSOL: main priorities for diabetes care
• COVID-19 and the Diabetes Patient: risks for death
• Role of SGLT-2- inhibitors: brief review of outcomes for patients
• Who to Prioritise in GP Care: Traffic-lights approach
• Care Planning: GP Systems and Care
• Final Remarks and Conclusions: Questions and Comments
Educational Objectives- to facilitate you to
• Be Informed of key statistics in relation to the local NDA
• Learn of COVID-19 risk factors for death
• Be informed of outcomes that can accrue from SGLT2-I Rx
• Become convinced of care planning in Diabetes Care
• Ask awkward questions
• Reflect on how you can change practice…..?
Diabetes Care in the time of COVID- 19
113. • Advice:
– Diet and weight control, Physical activity, not
smoking, Good Infection Control Measures,
Appropriate PPE, COVID-19 Symptoms,
• Blood Pressure:
– aim ≤ 140/85,
– CVD or CKD ≤ 130/85
• Cholesterol & CKD Prevention
– Most Atorvastatin 20mg or 80mg, TC ≈ 4 mmol/l
– UACR yearly and treat
• Diabetes Control:
– HbA1c < 59 (7.5%) usual target, ideal < 48 (6.5%)
– Outcome based Rx: ? SGLT2-i, ? GLP antagonists
– Safer insulins where needed
• Eyes:
– check yearly at least
• Feet:
– daily self-care, HCP check yearly at least
• Guardian Drugs:
– ?Aspirin 75mg (CVD atheroma), ?ACE-i, ARBs (esp
CKD, HF, CVD), appropriate SGLT-i
• Healthcare Progessional Advice:
– DVLA Advice and Occupation
– Hospital Admission Care
– Contraception Advice where needed
Alphabet Strategy for Diabetes
Care: “Checklist”
A Safety “Checklist”, Patient-Centred, Multi-Professional,
Evidence-based Approach
Targets Based on NICE Guidelines, EASD/ADA
Wong ND et al 2014: Am J Cardiol
JD Lee & V Patel 2015: World D J
Your Current Local Strategy can be adapted in the Time of COVID-19!
114. Birmingham and Solihull CCG
My Diabetes Self Management Plan
Works through GP Systems and printable to
give or post to patients
116. 122
Care plans provide direction for individualized care of the patient.
A care plan flows from each patient's unique list of diagnoses and
should be organized by the individual's specific needs. The care plan
is a means of communicating and organizing the actions of a
Healthcare Team to the patient and their carers.
RCN adapted
Ramadan
Care Plan
Based on Design by
Alia Gilani
adapted by
Raj Gill
117. 123
Care plans provide direction for individualized care of the patient.
A care plan flows from each patient's unique list of diagnoses and
should be organized by the individual's specific needs. The care plan
is a means of communicating and organizing the actions of a
Healthcare Team to the patient and their carers.
RCN adapted
Ramadan
Care Plan
Based on Design by
Alia Gilani
adapted by
Raj Gill
118. MDT Clinic advice during Ramadan
Current Treatment During Ramadan
Suhoor Gliclazide 160mg
Metformin 850mg
Ramipril 10mg od
Indapamide 2.5 mg od
Gliclazide 80mg
Metformin 850mg
Lunch Metformin 850mg
Iftar Gliclazide 160mg
Metformin 850mg
Simvastatin 40mg
Gliclazide 160mg
Metformin 850mg -1000mg
Ramipril 10mg od
Indapamide 2.5 mg od
Simvastatin 40mg
? Stop Gliclazide and start
a DPP-4i?
Kabir Ali
• 64-year-old, diabetes 16 years,
Taxi Driver
• Putting on weight- BMI 32.5
Taking:
• Simvastatin 40mg
• Ramipril 10mg od
• Indapamide 2.5 mg od
• Gliclazide 160mg bd
• Metformin 850mg tds
Clinical Data: 146/84, T-Chol 5.2
mmol/l, HbA1c 68mmol/mol = 8.4%,
Creatinine 98 umol/l,
eGFR 60ml/min
iftar
suhoor
119. • National Diabetes Audit (NDA) and BSOL: main priorities for diabetes care
• COVID-19 and the Diabetes Patient: risks for death
• Role of SGLT-2- inhibitors: brief review of outcomes for patients
• Who to Prioritise in GP Care: Traffic-lights approach
• Care Planning: GP Systems and Care
• Final Remarks and Conclusions: Questions and Comments
Educational Objectives- to facilitate you to
• Be Informed of key statistics in relation to the local NDA
• Learn of COVID-19 risk factors for death
• Be informed of outcomes that can accrue from SGLT2-I Rx
• Become convinced of care planning in Diabetes Care
• Ask awkward questions
• Reflect on how you can change practice…..?
Diabetes Care in the time of COVID- 19
120. There are several classes of drug that should be stopped if the
patient is at risk of dehydration due to acute illness:
Sick day rules for avoiding or recognising DKA1,2
S SGLT-2 inhibitors Increased risk of euglycaemic DKA
A ACE inhibitors Increased risk of AKI due to reduced renal
efferent vasoconstriction
D Diuretics Increased risk of AKI
M Metformin Increased risk of lactic acidosis
A ARBs Increased risk of AKI
N NSAIDs Increased risk of AKI due to reduced renal
efferent vasoconstriction
ACE, angiotensin converting enzyme; AKI, acute kidney injury; ARB, angiotensin receptor blocker; DKA, diabetic ketoacidosis; NSAID, nonsteroidal anti-inflammatory drug;
SGLT2, sodium-glucose co-transporter 2
1. How to advise on sick day rules. Available online at https://www.diabetesonthenet.com/journals/issue/457/article-details/how-advise-sick-day-rules. Accessed March 2020
2. Down S, et al. Diabetes and Primary Care, 2018, 20 (1 ), p 15-16
Signs and symptoms of DKA
• Excessive thirst
• Polyuria
• Dehydration
• Shortness of breath and laboured breathing
• Abdominal pain
• Leg cramps
• Nausea and vomiting
• Mental confusion and drowsiness
• Ketones can be detected on the person’s breath
(pear-drop smell) or in the blood or urine
121. Vitamin D supplements
• Reduced risk of acute respiratory tract infection approx 12%: adj. OR 0.88, 95%
CI 0.81-0.96)
• Protective effects were stronger with baseline Vit D levels <25 nmol Approx.
42%: Adj. OR 0.58, 0.40 to 0.82,
• Number Needed to Treat, NNT=8, 5 to 21). Not statistically significant effect in >
25nmol/L (adj. OR 0.89)
Buy it from Holland and Barrett- Nuneaton-based
and we need the cash! £8.49 – cheaper elsewhere
100 doses! – 3 months
Conclusions Vit D Supplementation was safe and
protected against Acute Respiratory Tract Infection
overall. Patients who were very vitamin D deficient
experienced the most benefit.
122. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of
individual participant data
Vitamin D supplements
• Reduced risk of acute respiratory tract infection approx 12%: adj. OR
0.88, 95% CI 0.81-0.96)
• Protective effects were stronger with baseline Vit D levels <25 nmol
Approx. 42%: Adj. OR 0.58, 0.40 to 0.82,
• Number Needed to Treat, NNT=8, 5 to 21). Not statistically significant
effect in > 25nmol/L (adj. OR 0.89)
Conclusions Vit D Supplementation was safe and protected against Acute
Respiratory Tract Infection overall. Patients who were very vitamin D deficient
experienced the most benefit.
Vitamin D supplementation to prevent acute respiratory tract infections: systematic
review and meta-analysis of individual participant data
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.i6583
123.
124.
125. How to undertake a Remote Diabetes Review- A PCDS Quick Guide
Jane Diggle and Pam Brown 2020
Videos and advice on (Diabetes UK mainly)
• Patient Foot Self-examination
• Weight. Waist Circumference
• Self-monitoring blood glucose
• Home BP Monitoring
Healthcare Professionals
• Remote Consultations
• NHS Guidance
• NICE Guidelines
Prioritise who to review based on
CVD and COVID-19 risks
Risk Stratification to re-establish Diabetes Care
Searches allow segmentation into manageable-sized
cohorts benefitting from early review
• High CD Risk: eg not meeting BP, Lipid, HbA1c NDA or,
QoF targets, those not on statins
• Risk factors for COVID-19 serious morbidity and
mortality: Increasing age, BAME, hyperglycaemia,
obese
• Previous non-attenders or review overdue
• On drugs increasing risk: insulins, Sulphonylureas,
SGLT2-i
• Recently diagnosed
• Consider referring those with Type 1 diabetes… with
poor control to local specialist
Diggle J, Brown P (2020)
How to undertake a remote diabetes review.
Diabetes & Primary Care 22: 43-5
https://youtu.be/kauYqodCx6w
126. Diabetes UK: Ipswich Touch Test
Designed by Professor Gerry Rayman and the team at
Ipswich Hospital
131. Key Messages
• Diabetes and COVID-19 mortality: distinct increase in mortality. Adjusted for age, sex,
deprivation, ethnicity and region: Type 1 DM x 3.50, Type 2 DM x 2.03.
• Glycaemic control and COVID-19 mortality: Adjusted Hazard ratio of HbA1c > 86
mmol/mol vs HbA1c 48-53 mmol/mol was 2.19 for T1 DM, 1.62 for T2 DM. T2 DM
significant increase > 58 mmol/mol
• “Clinical Phenotype” your Patient: to the appropriate glycaemic control agents that
fits, for the outcome desired by the patient, advised by the HCP
• Beyond age and male gender:
– Ethnicity & COVID-19 mortality: T1 DM: Black 1.79, Asian 1.68, T2 DM: Black 1.63, Asian* 1.09
– Deprivation: T1 DM: IMD 1,2,3 T2 DM: IMD 1,2,3
– Duration of Diabetes: Only T2 DM: greater than 15 years
– eGFR: Less than 60 for both T1 DM and T2 DM
– BMI: T1 DM ≥ 30, T2 DM ≥ 35
• Risk Stratification: could help identify diabetes patients, within a clinical service, that
need most urgent intervention where services are stretched and working in different
ways due to the COVID-19 Pandemic.
• NDA targets would be a good starting point.
Diabetes Care in the Time of COVID-19
*esp. Bangladeshi popn. PHE Disparities Report 2020
132.
133. 1: COVID-19 Infection Case
Definition: Community Care
Patients who meet the following
criteria and are well enough to remain
in the community
• new continuous cough and/or
• high temperature
• a loss or change to your sense of
smell or taste
Individuals with cough or fever should
now Stay at Home
134. 1: COVID-19 Infection Case
Definition: Community Care
Patients who meet the following
criteria and are well enough to
remain in the community
• new continuous cough and/or
• high temperature
• a loss or change to your sense of
smell or taste
Individuals with cough or fever should
now Stay at Home
135. Vitamin D supplements
• Reduced risk of acute respiratory tract infection approx 12%: adj. OR 0.88, 95%
CI 0.81-0.96)
• Protective effects were stronger with baseline Vit D levels <25 nmol Approx.
42%: Adj. OR 0.58, 0.40 to 0.82,
• Number Needed to Treat, NNT=8, 5 to 21). Not statistically significant effect in >
25nmol/L (adj. OR 0.89)
Buy it from Holland and Barrett- Nuneaton-based
and we need the cash! £8.49 – cheaper elsewhere
100 doses! – 3 months
Conclusions Vit D Supplementation was safe and
protected against Acute Respiratory Tract Infection
overall. Patients who were very vitamin D deficient
experienced the most benefit.
136. The Lancet Public Health 2020 5e475-e483DOI: (10.1016/S2468-2667(20)30164-X)
COVID-19 Cases in Healthcare Workers
Did the NHS succeed in coping with
the pandemic ?
138. The COVID-2019 Vaccine- A Holy Grail ?
NB: Deal with AstraZeneca, shifts some of the risks involved in the
roll-out of a vaccine to taxpayers in UK and EU
WHO Update: September 2020
• ….Racing to find a vaccine. Vaccines save millions of lives each year.
Vaccines work by training and preparing the immune system to
recognize and fight off viruses and bacteria. The body is then
immediately ready to destroy them, preventing illness.
• Vaccines prevent 2 to 3 million deaths per every year - diphtheria,
tetanus, pertussis, influenza and measles. There are now vaccines to
prevent more than 20 life-threatening diseases
• Currently over 169 COVID-19 vaccine candidates under development,
with 26 of these in the human trial phase
• WHO will facilitate equitable access and distribution of these vaccines
to protect people in all countries. People most at risk will be prioritized.
140. • Introduction to the Virus and Pandemic
• Diagnosis
• The High Risk Patients
• Infection Control Looking after yourselves
• Clinical Care: GPs and Hospitals
• Any Comments and Questions
Life in the Time of COVID-19
…Thoughts, Protection Strategies and the Future
Educational Objectives- to facilitate you to
• Be Informed of key statistics in relation to COVID-19
• Discuss an interesting fact at dinner with your family
• Be better informed to protect your and your loved ones
• Ask awkward questions
• Reflect…..?
Thank You very much for the opportunity!
And Namaste!
Hinweis der Redaktion
People living with diabetes have a significantly higher risk of mortality with COVID-19.
But people with type 1 diabetes are at a higher risk of mortality with COVID-19 than patients with type 2 diabetes.
Reducing HbA1c is a key to addressing other potential complications.
CORE SLIDE
Observational data based on the UKPDS has demonstrated the association of good blood glucose control with a reduced burden of microvascular and macrovascular complications.1
Link to next slide:
How are we doing currently?
Reference
Stratton IM et al. BMJ 2000; 321: 405–412.
BSol CCG – My Diabetes Self Management Plan
All delegates will have this in there delegate packs as this slide will not be easily read on the screen
Explain where they can find this on the system and how to use it etc.
Any questions regarding this ?