Improving health outcomes in COVID19: Use of flash glucose monitoring in diabetic ketoacidosis

ABSTRACT

Introduction: COVID-19 has been linked to an increased risk of new-onset diabetes mellitus and increased incidence of diabetic ketoacidosis (DKA) either as a new presentation or with pre-existing diabetes. Various mechanisms such as impaired insulin secretion, impaired glucose disposal or increased counter regulatory responses are proposed.2 Case report A 57-year-old man diagnosed with COVID-19 one month prior presented with epigastric pain, shortness of breath and weight loss. Investigations confirmed DKA (pH 7.22, bicarbonate 2.6 mmol/L, blood glucose 11.6 mmol/L, blood ketones 5.8 mmol/L) with HbA1c of 95 mmol/mol. Initial treatment was started as per national DKA guidelines. Upon discharge, the patient was prescribed a basal-bolus regime (total 30 units of insulin) and a FreeStyle Libre flash glucose monitoring (FGM) device. Rapid improvement in blood glucose levels was observed, with regular down titration of insulin and complete discontinuation after 24 days. HbA1c was 37 mmol/mol 96 days later. C-peptide normalised at 3 months for paired glucose at 837 pmol/L. Discussion: The use of diabetes technology (FGM device) with remote monitoring of blood glucose was instrumental in the safe and effective management of this patient. Given that the available literature suggests transient beta-cell dysfunction in the majority of COVID-19 patients resulting in DKA,3 we propose that patients who have been diagnosed with COVID-19 presenting with DKA should be discharged with insulin and FGM from secondary care. This enables remote insulin titration with ease, de-escalation of treatment with confidence and avoiding hypoglycaemia in the recovery phase of the illness in those with transient beta-cell dysfunction due to COVID-19.