ABSTRACT
Background: Dexamethasone is being increasingly used in the treatment of covid-19 pneumonitis, leading to hyperglycaemia in patients both with and without diabetes. Pandemic related capacity issues are causing inpatient diabetes teams to become stretched with facilitating early supported discharges, where steroid induced hyperglycaemia requiring insulin has occurred. Protocolised solutions are therefore required to counter this problem. Aims: To design a de-escalation pathway using an objective means (HbA1c) to guide non-specialist teams with the management of anti-hyperglycaemic agents initiated during admission for covid-19 pneumonitis and follow-up requirements. Methods: Patients with covid-19 infection on dexamethasone referred to the inpatient diabetes team over a 2-week period were subcategorised using HbA1c values, to determine the need for ongoing insulin therapy and appropriate follow-up. Results: Of 121 referrals, dexamethasone was initiated in 95% of cases leading to steroid induced hyperglycaemia. HbA1c was measured in 61 cases. Only three cases had HbA1c values below the 48 mmol/mol cut-off. These were considered low-risk and suitable for GP follow-up. However, 38 cases (62%) had HbA1c values greater than 70 mmol/ mol and thus required insulin therapy on discharge, intensive glucose monitoring and specialist follow-up at 48 hours post-discharge. Conclusion: We suggest measuring HbA1c at the point of admission for all patients presenting with suspected covid- 19 infection. Where electronic phlebotomy requests exist, covid-19 admission bundles which include HbA1c may be helpful. HbA1c values can serve as a tool to provide non-specialist teams with a diabetes care plan on how to de-escalate insulin therapy, glucose monitoring requirements and advise on appropriate follow-up. Review of readmission/ harm is currently ongoing.
ABSTRACT
Background: Hyperglycaemia during admission with covid- 19 is associated with worse outcomes. Dexamethasone is used in severe covid-19. The national guidance suggests using prn quick acting insulin followed by twice daily intermediate acting insulin (0.3 units/kg) if blood glucose continues >12 mmol/L. Aim: To evaluate insulin requirements in inpatients with covid-19 and treated with steroids. Methods: Four rapid iterative quality improvement cycles evaluated the strategy for initiating insulin for patients with persistent hyperglycaemia (>11 mmol/L) and given steroids in an inner city teaching hospital trust. We identified consecutive referrals to the inpatient diabetes team. Exclusions include <7 days of steroids course, admission to intensive care or intravenous insulin. Electronic records were reviewed. Results are mean±SD. Results: Thirty-two referrals identified (63% male), type 2 diabetes 78%/22% no history of diabetes, 66 ± 11 years old, weight 90 ± 24 kg, HbA1c 75 ± 2.8 mmol/mol. covid-4C score 11/21 indicating high-risk patients. Seven days cumulative dexamethasone (or equivalent) dose was 48±23 mg. Admission glucose was 11.5 ± 5.7 mmol/L peaking on day 2 of steroids course (15.2 ± 4.4 mmol/L) and declining to nadir of 11.7 ± 4.2 mmol/L on day 6. Total daily insulin requirements rose rapidly from 0.07 ± 0.18 units/kg (day 1) to a peak of 0.72 ± 0.8 units/kg (day 4) and nadir of 0.64±0.7 units/kg (day 7). Conclusions: We found insulin requirements suggested in the national guidance to be a conservative estimate. In our cohort it is more than doubled in a short period of time requiring rapid titration. Learnings from this work informed the rapid adaptation of the local guidance by advocating early introduction of scheduled intermediate acting insulin when pre-steroids blood glucose is ≥11 mmol/L.