COVID 19, Diabetes & Diabetic Ketoacidosis:

What is the Correlation & How to Manage It?

Ketut Suastika
Webinar PB Perkeni bekerjasama dengan PT Sanofi Indonesia
15 April 2020
Agenda
1. COVID 19: Epidemiology and Clinical Appearance
2. Diabetes and Immune Dysfunction
3. General and Specific Precautions in People with Diabetes
4. Management of Diabetes with COVID 19
Agenda
1. COVID 19: Epidemiology and Clinical Appearance
2. Diabetes and Immune Dysfunction
3. General and Specific Precautions in People with Diabetes
4. Management of Diabetes with COVID 19
 WHO global health emergency
• 31 December 2019: 27 cases of pneumonia of unknown aetiology
were identified in Wuhan City, Hubei province in China
• 7 January 2020: The Chinese Centre for Disease Control and
Prevention (CCDC), and was subsequently named Severe Acute
Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).
• On 30th January 2020: WHO declared outbreak a Public Health
Emergency of International Concern
• 11 February 2020: The coronavirus disease was named COVID-19 by
the World Health Organization (WHO)

Sohrabi C et al. World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). International Journal of Surgery 76 (2020) 71–76
WHO. Int. Corona Virus (COVID 19) Report. Access 13 April 2020
 Clinical presentation of COVID 19
WHO: 3 March 2020
Clinical presentation • Fever
• Cough
• Shortness of breath
Incubation period • 2–14 days
Number infected globally • 90,870
Deaths globally • 3,112
Mortality • 3.4%

Loss of smell and taste are more recently identified symptoms

Sohrabi C et al. World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). International Journal of Surgery 76 (2020) 71–76
 Epidemic curve of confirmed COVID-19, by date of report and
WHO region through 14 April 2020

20 January 2020 14 March 2020 14 April 2020 Indonesia*

Globally conformed 282 (China, Japan, 142,534 1,844,863 4,893
Korea, Thailand)
Death - 5,392 117,021 459 (9.4%)
* Gugus Tugas Percepatan Penanganan COVID-19. Covid19.go.id. Akses 15 April 2020
Novel Coronavirus Infection (COVID- Prevalence of comorbidities in the Novel
19) in Humans: A Scoping Review and Wuhan Coronavirus (COVID-19) infection:
Meta-Analysis a systematic review and meta-analysis.

A total of 61 studies were included The most prevalent clinical symptom was:
(59,254 patients). The most common • Fever ( 91±3%)
• Cough (67±7%)
disease-related symptoms were:
• Fatigue ( 51±0%)
• Fever (82%) • Dyspnea ( 30±4%)
• Cough (61%) The most prevalent comorbidity were:
• Muscle aches and/or fatigue (36%) • Hypertension (17±7%)
• Dyspnea (26%) • Diabetes (8±6%)
• Cardio vascular disease (5±4%)
• Headache (12%) • Respiratory system disease (2±0%)
• Sore throat (10%) Compared with the Non-severe patient, the pooled odds
• Gastrointestinal symptoms (9%) ratio of hypertension, respiratory system disease
cardiovascular disease in severe patients were (OR 2.36,
95% CI: 1.46-3.83) ,(OR 2.46, 95% CI: 1.76-3.44) and (OR
3.42, 95% CI: 1.88-6.22)respectively.

do Nascimento IJB et al. J. Clin. Med. 2020, 9, 941; doi:10.3390/jcm9040941

Yang J et al. Internat J Infect Dis (2020), doi:https://doi.org/10.1016/j.ijid.2020.03.017
 Estimates of case fatality ratio by age, obtained from aggregate
data from mainland China

Verity R et al. Lancet Infect Dis 2020 . https://doi.org/10.1016/S1473-3099(20)30243-7

 How Does COVID-19 Spread?

• Exact dynamics yet to be determined

• Person-to-person transmission
• Respiratory droplets or close contact
Air – by coughing and sneezing
• Mean incubation period ~ 5 days (range
1-14 days)
• In 95% of cases, symptoms within 12.5
days of contact Touching a surface Close personal contact
with virus on it – then – such as touching or
• 1 person likely to infect 2.6 persons touching mouth, nose
or eyes
shaking hands

Chan JF et.al. Lancet. 2020;395(10223):514-523 COVID-19 – Coronavirus disease-2019

Agenda
1. COVID 19: Epidemiology and Clinical Appearance
2. Diabetes and Immune Dysfunction
3. General and Specific Precautions in People with Diabetes
4. Management of Diabetes with COVID 19
 Innate immunity Adaptive immunity
Role of innate
immunity and adaptive
immunity in the
condition of T2DM1

Summary of the Humoral Cellular

different immune Innate Compliment ↓ PMNs ↓=
dysfunctions Cytokines without stimulation
Cytokines after stimulation
↑
↓=
Monocytes/macrophages ↓

found in diabetic Adaptive Immunoglobulins = T lymphocytes ↓

patients2 Adherence ↑

1. Zhou T et al. J Diabetes Res 2018. https://doi.org/10.1155/2018/7457269; 2. Geerlings SE et al. FEMS Immunology and Medical Microbiology 26 (1999) 259^265
 Pathophysiology of infections associated with diabetes mellitus
Lower secretion of
↓T lymphocytes response Diabetes mellitus
inflammatory cytokines

↓Neutrophil function Glycosuria

Disorders of humoral
GIT dysmotility
immunity

Anti-oxidant system
depression Hyperglycemia: increased
virulence of infectious
microorganisms and
Large number of apoptosis of PMN
Angiopathy Neuropathy
medical interventions

INFECTIONS
Casqueiro J et al. Indian J Endocrinol Metab 2012; 16 (Suppl 1): S27. DOI: 10.4103/2230-8210.94253
Link between hyperglycemia and poor hospital outcome
Metabolic stress response
Stress hormones and peptide

Glucose
Insulin
Immune dysfunction Reactive O2 species Platelet aggregation
FFA
Ketones Transcription factors  tPA activity
Lactate
Infection dissemination
Secondary mediators PAI levels
Cellular injury/apoptosis
Inflammation
Tissue damage
Altered tissue/wound repair
Acidosis
Infarction/ischemia

Prolong hospital stay

Disability
Death
Deedwania P et al. Circulation. 2008;117:1610-1619 . Modified from Clement et al. 2004
Agenda
1. COVID 19: Epidemiology and Clinical Appearance
2. Diabetes and Immune Dysfunction
3. General and Specific Precautions in People with Diabetes
4. Management of Diabetes with COVID 19
 Characteristics of and Important Lessons From
the Coronavirus Disease 2019 (COVID-19) Outbreak in China
Summary of a Report of 72 314 Cases From
the Chinese Center for Disease Control and Prevention

• Case-fatality rate (CFR)

• 2.3% (1023 of 44 672 confirmed cases)
• 14.8% in patients aged >80 years (208 of 1408)
• 8.0% in patients aged 70-79 years (312 of 3918)
• 49.0% in critical cases (1023 of 2087)
• CFR was elevated among those with preexisting
comorbid conditions 3 fold higher mortality
• 10.5% for cardiovascular disease rate in diabetes
• 7.3% for diabetes
• 6.3% for chronic respiratory disease
People with diabetes do face a higher
• 6.0% for hypertension
chance of experiencing serious
complications from COVID-19*
• 5.6% for cancer.

Wu Z and McGoogan JM. JAMA Published online February 24, 2020. https://jamanetwork.com/ on 02/24/2020
*Gupta R et.al. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 211e212
What Are The General Precautions To Be Taken?

Hand hygiene & Respiratory hygiene

Breaking the chain to

limit the spread

Social distancing & Avoid non-essential travel

Gupta R et.al. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 211e212
 What Are The Specific Precautions For People With
Diabetes?

Good glycemic control Frequent monitoring Stabilize cardiac/renal status

(Reduces risk & severity of infection) (Use of SMBG should be encouraged) (Reduce chances of serious complications)

Proper nutrition & adequate Regular exercise Self-quarantine

protein intake (Improves immunity, Avoid crowded places) (Especially in high risk patients like elderly)
(Correct deficiency of vitamins & minerals)

Influenza & pneumonia vaccinations may lessen chances of secondary bacterial pneumonia

Gupta R et.al. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 211e212
Agenda
1. COVID 19: Epidemiology and Clinical Appearance
2. Diabetes and Immune Dysfunction
3. General and Specific Precautions in People with Diabetes
4. Management of Diabetes with COVID 19
 Reasons for glucose fluctuation in patients with diabetes and
COVID 19
There may be interruption or non-
Irregular diet, reduced exercise,
standard treatment with OAD in
gastrointestinal symptoms, etc.,
isolation wards, resulting in glucose
affect diet, resulting in glucose
fluctuation
fluctuation

Fear, anxiety and tension may

Stress conditions like increase glucose level and
infection increase induce glucose fluctuation
glucocorticoids secretion

COVID 19 can cause human body to

produce a large number of
The use of glucocorticoids in
inflammatory cytokines and lead to
treatment can lead to a sharp
extreme stress in some severe and
rise in glucose
critical patients
Expert Recommendation on Glucose Management Strategies of Diabetes Combine with COVID-19. J Clin Intern Med 2020 Mar; 37 (3): 215-219
NHS: Clinical guide for the management of people
with diabetes during the coronavirus pandemic
Categories of people with diabetes to consider:
• Obligatory admissions and inpatients: Continue to require admission and
medical management, eg. diabetic ketoacidosis (DKA). We must expedite
treatment to avoid delay and expedite discharge to minimise length of stay.
• Secondary care services: Outpatient attendances should be kept to the safe
minimum. Consider using virtual clinics and remote consultations.
• Primary care delivered diabetes services: Implications for routine diabetes
care should be considered in the context of broader long-term condition
management and prioritisation, taking into account individual risk factors and
clinical needs.

NHS. Specialty guides for patient management during the coronavirus pandemic. 19 March 2020 Version 2. Publications approval reference: 001559.
 Glucose management strategies for different clinical
classification
• Both OAD and insulin treatment can be maintained and it is not necessary to adjust
original regimen
• Progress of COVID-19 can be rapid and worsen with hyperglycemia. It is recommended
Mild in diabetes patients with COVID-19, even mild, to increase glucose measurement
frequency, and consult with physician to adjust regimen in time if glucose target cannot
be achieved

• Maintain original regimen if patient’s mental condition, appetite and glucose control are
within normal range
Moderate • Switch OAD to insulin for patients with obvious COVID-19 symptoms who cannot eat
regularly
• Suggest switching premix insulin regimen to basal-bolus regimen or insulin pump to flexibly
manage glucose

• IV insulin should be the first-line treatment

Severe • For patients who are process of continuous renal therapy (CRRT), the proportion of
and glucose and insulin in the replacement solution should be increasd or decreasd
according to glucose monitoring result to avoid hypoglycemia and severe3 glucose
critical fluctuation
Expert Recommendation on Glucose Management Strategies of Diabetes Combine with COVID-19. J Clin Intern Med 2020 Mar; 37 (3): 215-219
 Target stratification of glucose management
🏥Tagret stratification of glucose management:
• For mild and moderate non-elderly COVID 19 patients, stick to strict high control target
• For mild and moderate elderly patients, or patients who have been using glucocorticoid, set up a low
or medium control target
• For severe and critical patients, elderly patients, hypoglycemia intolerance patients, or patients who
have organ dysfunction or serious cardiovascular and cerebrovascular diseases, set up a low control
target

🏥Target stratification of glucose management in hospital patients

High Medium Low
FPG/PrePG (mg/dl) 80-110 110-140 140-180
2hPPG (mg/dl) 110-140 140-180 140-250

🏥Hypoglycemia occurrence should be minimized during glucose management in diabetes patients with
COVID 19. Medical care should be performed in time if hypoglycemia occurs.

Expert Recommendation on Glucose Management Strategies of Diabetes Combine with COVID-19. J Clin Intern Med 2020 Mar; 37 (3): 215-219
 Therapeutic principle of glucose management

• Insulin treatment is the first choice if diabetes is combine with severe infection:
• For non-critical patients, insulin SC injection is recommended, and basic dosage can refer to
the out-of-hospital dosage
• For critical patients, CSII is recommended
• IV insulin treatment should be started in combination with aggressive fluid infusion if serious
glucose metabolism disorder with water and electrolyte and acid-base disorders is seen
• If clinical condition is stable and eating pattern is regular, patients can continue
OAD treatment as before admission
• Using NPH and long-acting insulin during glucocorticoid treatment to control
glucose. Measure 7 point glucose (If necessary, plus nocturnal glucose) during
insulin treatment

Expert Recommendation on Glucose Management Strategies of Diabetes Combine with COVID-19. J Clin Intern Med 2020 Mar; 37 (3): 215-219
Precautions With Anti-diabetic Agents:
Analyze risk-benefit individually

Consider temporary dose reduction/discontinuation in seriously symptomatic cases

Metformin SGLT2i GLP1RA TZD

Raise lactic acid levels, Volume contraction, Can cause vomiting Volume overload
acidosis fat metabolism,
ketosis

1. Gupta R et.al. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 211e212 ; 2. Lea-Henry TN et.al. Aust Prescr. 2017 Oct; 40(5): 168 - 173.
 How to Control Hyperglycemia In Sick Patients Where Dose
Of Other Anti-diabetic Medications is Reduced/ Withdrawn?

In all patients where anti-hyperglycemic medications are

being considered for temporary dose reduction/ discontinuation
- Basal insulin with or without bolus is to be used to maintain
good glycemic control

Insulin remains the drug of choice in sick patients

American Diabetes Association. Diabetes Care 2020; 43(Suppl 1): S77-S88.
Guideline Recommendations On Insulin Initiation
Guideline/ Basal Premixed
Recommendation
Guideline/ Basal Premixed
Recommendation
ADA-EASD 20181 I
ADA-EASD 20181 I
IDF 20173 I Till 2016
IDF 20173 I Till 2016
CDA4 I
CDA4 I • Guidelines are unanimous in
NICE55 I
NICE I recommending basal insulin at
RSSDI66
RSSDI
I
I
I
I
initiation
8
• Second generation basal insulin can
ESC
ESC 2019
20198 II
offer additional benefit of lesser
ADA
ADA 2020
7
20207 II Till
Till 2014
2014 hypoglycemia, lesser variability,
AACE 20202 I Till 2014
safer titration and greater flexibility

ADA 2020 guidelines recommend basal insulin as

the ‘most convenientinitial insulin regimen’ in patients with T2DM

1. Davies MJ, et al. Diabetes Care. 2018;41(12):2669–2701. 2. Garber AJ, et al. Endocr Pract. 2018;24(1):91–120. 3. IDF Clinical practice recommendations for managing type 2 diaetics in primary care.
2017. Available at: https://www.idf.org/component/attachments/attachments.html?id=1270&task=download. Accessed on: Dec 03, 2018. 4. CDA. 2018 Clinical Practice Guidelines Committeesb. Available at:
21
http://guidelines.diabetes.ca/docs/CPG-2018-full-EN.pdf Accessed on: Dec 06, 2018. 5. NICE. Available at: https://www.nice.org.uk/guidance/ta53/documents/final-appraisal-determination-longacting-insulin-
analogues-for-the-treatment-of-diabetes-insulin-glargine-2 Accessed on: Dec 06, 2018. 6. Bajaj S. RSSDI Guidelines 2017. 7. ADA. Standards of Medical Care in Diabetes—2020. 8. Cosentino F, et al. 2019
ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases. Eur Heart J. 2019 Aug 31
FAQs On Basal Insulin

Question Answer
What is the initiation dose? 0.1-0.2 units/kg*
What is the preferred timing of injection? Anytime of the day at the same time

Can OADs be continued with basal insulin? Appropriate OADs can be continued
What is the titration regimen? Can be safely titrated using daily, once in 3
days or weekly titration schedules

Up to what dose can basal insulin be titrated? 0.5 units/kg/day

Can basal insulin be prescribed in special Yes
population like elderly, CKD, pregnancy?

*Initiation dose for Gla-300 as per label is 0.2 units/kg

•American Diabetes Association. Diabetes Care 2020; 43(Suppl 1): S77-S88. OAD – Oral antidiabetic drugs; Gla-100 – Insulin glargine 100 units/mL; Gla-300 – Insulin glargine 300 units/mL; CKD – Chronic kidney disease
In Hospital Management of Hyperglycemia
Level of Glycemic target Insulin Route of Dose calculation
care (mg/dl) administration
ICU 140-180 Regular human IV Adjust insulin infusion rate based on the
insulin blood glucose values
Non-ICU Fasting PG: 80-120 Basal insulin SC • Total insulin needed in previous 24 h
Premeal PG: <140 Bolus insulin (TDD)
Postmeal PG: <180 (Insulin analog • 50% Basal
preferred) • 50% Bolus
• Individualized correctional bolus
Avoid sliding scale insulin

Panikar V et.al. Int J Diabetes Dev Ctries RSSDI (November 2016) 36 (Suppl 1):S1–S21 26 i.v- intravenous; s.c-subcutaneous
Calculate Starting Total Daily Dose (TDD)
• 0.2-0.3 units/kg/day in patients: aged 70 yr and/or GFR < 60 ml/min
• 0.4 units/kg/day for patients not meeting the criteria above who have BG 180–250 mg/dl
• 0.5 – 0.6 units/kg/day for patients not meeting the criteria above when BG is > 250 mg/dl

TDD Estimation Patients Characteristics

0.3 units/kg BW Underweight
Older age
Hemodialysis
0.4 units/kgBW Normal weight
0.5 units/kg BW Overweight
>0.6 units/kg BW Obese
Insulin resistant
Glucocorticoids

Modified Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97(1):16-38

Do we need to worry about DKA (Diabetic
ketoacidosis)?

• When sick with a viral infection, people with diabetes do face an increased risk of
DKA (diabetic ketoacidosis), commonly experienced by people with type 1
diabetes.
• DKA can make it challenging to manage your fluid intake and electrolyte levels—
which is important in managing sepsis. Sepsis and septic shock are some of the
more serious complications that some people with COVID-19 have experienced.
• If your blood sugar has registered high (greater than 240 mg/dl) more than 2
times in a row, check for ketones to avoid DKA.

ADA. diabetes.org. Access 31 Match 2020

Diabetic Ketoacidosis (DKA) and
Hyperglycemic Hyperosmolar State (HHS)
o DKA and HHS
• Suspected in every ill patient with hyperglycemia
o DKA
• Precipitating factors: new diagnosis of DM, infection, Poor adherence of treatment, others
• Polyuria, polydipsia and weight loss-in hours to days
• Nausea, vomiting and abdominal pain (40-75% cases)
• Physical exam: dehydration, change of mental status, hypothermia, scent of acetone on patient’s breath, Kussmaul
respiration (severe metabolic acidosis)
o HHS
• HHS occurs most commonly, but not exclusively, in older people with type 2 diabetes and accompanying comorbidities.
• Precipitating factors include pneumonia (40– 60%) and urinary tract infections (5–16%) or other acute conditions such as
cerebrovascular disease, myocardial infarction, or trauma
• Slower onset (several days). The risk of HHS increases in settings of inadequate fluid intake due to altered thirst mechanisms
with aging or inability to access fluids.
• More severe manifestations of hyperglycemia, dehydration and plasma osmolality, all which correlate with impaired levels of
consciousness
• Symptoms of encephalopathy are present when serum Na levels >160 mmol/l and effective serum osmolality >320

Umpierrez G and Korytkowski M. Nature Rev 2016; 12: 222-232

French EK et al. BMJ 2019;365:l1114 doi: 10.1136/bmj.l1114
 DKA HHS
Mild Moderate Severe Plasma glucose
(plasma glucose (plasma glucose (plasma glucose >600 mg/dl
>250 mg/dl) >250 mg/dl) >250 mg/dl)
Arterial pH 7.25–7.30 7.00–<7.24 <7.00 >7.30
Serum bicarbonate (mEq/l) 15–18 10-<15 <10 >18

Urine ketone* Positive Positive Positive Small

Serum ketone* Positive Positive Positive Small
Effective serum osmolality† Variable Variable Variable >320 mOsm/kg

Anion gap‡ >10 >12 >12 Variable

Mental status Alert Alert/drowsy Stupor/coma Stupor/coma

*Nitroprusside reaction method. †Effective serum osmolality: 2[measured Na+ (mEq/l)] + glucose (mg/dl)/18. ‡Anion gap: (Na+) – [(Cl- + HCO3- (mEq/l)].

Kitabchi AE et al. ADA Consensus Statement. Diab care 2009; 32: 1335-1343
Pathogenesis of DKA and HHS: stress, infection, or
insufficient insulin
Absolute Insulin Counterregulatory Relative Insulin
deficiency Hormone deficiency

Lipolysis
Protein synthesis Proteolysis
Absent or minimal
++ ketogenesis
FFA to liver Gluconeogenic substrates

Ketogenesis
Glucose utilization Gluconeogenesis Glycogenolysis
Alkali reserve
Hyperglycemia

Ketoacidosis Glycosuria (osmotic diuresis)

Triacylglyerol Loss of water and electrolytes

Decreased fluid intake
Dehydration Hyperosmolarity
Hyperlipidemia
Impaired renal function
HHS
DKA

Kitabchi AE et al. ADA Consensus Statement. Diab care 2009; 32: 1335-1343
Protocol for management of adult patients with DKA and HHS recommended by
the ADA

Umpierrez G and Korytkowski M. Nature Rev 2016; 12: 222-232

Treatment of hyperglycemic crisis
Intravenous fluids
1000–2000 ml 0.9% NaCl over 1–2 h for prompt recovery of hypotension and/or hypoperfusion. Switch to 0.9% saline or 0.45% saline at 250–500
ml/h depending upon serum sodium concentration. When plasma glucose level ~11.1 mmol, change to dextrose in 5% saline.
Insulin
Regular human insulin intravenous bolus of 0.1 U/kg followed by continuous insulin infusion at 0.1 U/kg/h. When glucose level ≤13.9 mmol/l,
reduce insulin rate to 0.05 U/kg/h. Thereafter, adjust rate to maintain glucose level ~11.1 mmol/l. Subcutaneous rapid-acting insulin analogues
might be an alternative to intravenous insulin in patients with mild-to-moderate DKA.
Potassium
Serum potassium level >5.0 mmol/l (no supplement is required); 4–5 mmol/l (add 20 mmol potassium chloride to replacement fluid); 3–4 mmol/l
(add 40 mmol to replacement fluid); <3 mmol/l (add 10–20 mmol/h per hour until serum potassium level >3 mmol/l, then add 40 mmol to
replacement fluid).
Bicarbonate
Not routinely recommended. If pH <6.9, consider 50 mmol/l in 500 ml of 0.45% saline over 1 h until pH increases to ≥7.0. Do not give bicarbonate
if pH ≥7.0.
Laboratory evaluation
Initial evaluation should include blood count; plasma glucose; serum electrolytes, urea nitrogen, creatinine, serum or urine ketone bodies,
osmolality; venous or arterial pH; and urinalysis. During therapy, measure capillary glucose every 1–2 h. Measure serum electrolytes, blood
glucose, urea nitrogen, creatinine and venous pH every 4 h.
Transition to subcutaneous insulin
Continue insulin infusion until resolution of ketoacidosis. To prevent recurrence of ketoacidosis or rebound hyperglycaemia, continue intravenous
insulin for 2–4 h after subcutaneous insulin is given. For patients treated with insulin before admission, restart previous insulin regimen and adjust
dosage as needed. For patients with newly diagnosed diabetes mellitus, start total daily insulin dose at 0.6 U/kg/day. Consider multi-dose insulin
given as basal and prandial regimen.

Umpierrez G and Korytkowski M. Nature Rev 2016; 12: 222-232

Insulin Analogs Versus Human Insulin in the Treatment of
Patients With Diabetic Ketoacidosis

IV Insulin Glulisine (n=34) Transition to SQ

Total daily dose 0.6 U/kg/day
0.1 U/kg/hr until BD <250
mg/dl then 0.05 u/kg/hr until Given 1/2 as glargine OD, and
resolution of DKA 1/2 as glulisine before meals
68 Subjects
with DKA

IV Regular insulin (n=34) Transition to SQ

Total daily dose 0.6 U/kg/day
0.1 U/kg/hr until BD <250
mg/dl then 0.05 u/kg/hr until Given 2/3 as NPH, and 1/3 as
resolution of DKA regular insulin twice daily

Umpierrez GE et al. Diabetes Care. 2009;32:1164–1169

Changes in metabolic profile in patients with DKA treated with intravenous glulisine (white circle) and regular
insulin (black circle)
Umpierrez GE et al. Diabetes Care. 2009;32:1164–1169
Key Considerations

People with diabetes have greater chances of serious complications from COVID-19

People with diabetes are at increased risk of mortality from COVID-19

Risk & severity of COVID-19 in people with diabetes can be reduced with general
precautions, good glycemic control and proper monitoring
When anti-diabetic medications are considered for temporary dose reduction/
discontinuation, basal insulin+bolus can be used for good glycemic control

Insulin is the preferred agent for control of hyperglycemia in hospitalized patients

Thank you