March 31, 2020
The COVID-19 pandemic is a very worrisome time for everyone, especially those with additional health concerns. To support and inform the T1D community, JDRF Canada consulted a panel of Canadian endocrinologists (listed below) to provide answers to some of your most frequently asked questions.
First and foremost, the importance of good hygiene and social distancing in reducing the risk of infection or spreading infection to others cannot be stressed enough.
Each person with T1D is different, and we would encourage you to discuss your needs with your healthcare team – the answers below should not be taken in place of medical advice. In addition, the situation with COVID-19 is changing rapidly, with new evidence emerging every day. This information is current as of March 25th, 2020.
Q: Are people with T1D at higher risk of being infected with the virus that causes COVID-19?
There is no evidence that people with T1D are at increased risk of being infected by SARS-CoV-2, the virus that causes COVID-19. Reports from other countries that have implied that people with diabetes may be at higher risk of coming down with COVID-19 might be explained by the fact that people with diabetes had more frequent interactions with other patients and healthcare providers early during the outbreak, when the importance of social distancing was not yet known.
Q: Why do people with diabetes have a worse prognosis when they get COVID-19?
Based on what is known about other viral infections, if a person with T1D comes down with COVID-19, the consequences might be more severe, particularly if they have other health concerns or complications from diabetes (such as heart disease, heart failure, kidney disease) and/or are above the age of 70. In addition, managing blood glucose during an infection is difficult and adds an additional layer of complexity to treatment. If someone with T1D is struggling with illness management when sick with COVID-19, they could be at increased risk of ketosis and diabetic ketoacidosis (DKA), of other (bacterial) infections if they have very high blood sugar, or of hypoglycemia.
A large proportion of people who have died from COVID-19 in China had diabetes – but most of these were likely people with type 2 diabetes, who are on average older than people with type 1 diabetes. It is also not yet clear whether diabetes itself causes worse outcomes, or whether worse outcomes are seen because people with diabetes often have other medical conditions (such as heart or kidney disease) that increase risk. Research in progress will hopefully provide more information on these uncertainties soon. As with any disease, each individual is different, and we encourage you to consult your healthcare team to discuss your risks.
Q: Do people with T1D need to take extra precautions to avoid getting COVID-19, above and beyond those recommended for the general population?
Social distancing is crucial at this time to protect yourself and others from exposure. We all have a part to play in minimizing the impact of the COVID-19 outbreak in Canada, and each of us can set a good example: stay home as much as possible, use virtual options for work or socializing, ask a delivery service or a friend to bring groceries, and keep 2 m away from others if you must go out. For clinic visits, please check with your healthcare team about options for video or phone visits, and delay routine lab work unless there is a clear and urgent need.
If you struggle with your glucose control and have a complication such as heart or kidney disease, or if you are older (~60 years or older), we would encourage you to consider taking all steps possible to minimize potential exposure. If you have high HbA1c (>9%), you may also wish to monitor blood sugar closely and work with your healthcare team (by phone or video) to safely reduce this over the coming weeks when COVID-19 may remain a problem, as lowering your HbA1c could mean a lesser impact of COVID-19 if you do become sick.
Q: My child has T1D – is he or she at high risk compared with a child who does not have T1D?
In general, children who become sick with COVID-19 have mild disease. There is still no published evidence about COVID-19 in children with T1D, but anecdotal evidence from Europe suggests that children with T1D who become ill usually have mild disease and that many children can be managed safely at home with appropriate management of illness.
However, children and youth are not immune to serious illness and in this situation it is important to prevent possible DKA (a serious and life-threatening condition), severe hypoglycemia, and dehydration. During times of illness, it is important to monitor blood glucose and ketones as indicated, follow guidelines as well as connect with your local diabetes team as needed. We recommend ensuring that ketone testing supplies (urine and/or blood strips) have not expired, and being ready to give extra rapid-acting insulin, if required, if your child has elevated glucose and ketones ̶ as often as every 3-4 hours if indicated. Following illness management guidelines through your diabetes clinic is recommended. For example, here is a useful link to information on illness management from Ontario’s Provincial Council for Maternal and Child Health. Additional details in English and French can be also accessed here.
Q: Is our insulin supply in Canada under threat? How about diabetes supplies or devices?
Thus far, we are aware of no disruptions to the supply chain for medications including insulin, or for diabetes devices. For a list of notices from specific manufacturers, please visit www.jdrf.ca/t1d-and-covid-19/. However, the availability of some medicines (including insulin) in individual pharmacies is being affected as many consumers have been requesting more medicines than usual. We are continuing to monitor the situation and provide information and support. If you cannot obtain insulin, we encourage you to reach out directly to your insulin manufacturer’s customer care team.
Q: I’ve heard that certain blood pressure-lowering medications (ACEis and/or ARBs) might increase my risk of coming down with COVID-19. Is it safe to keep taking these medications?
There is no good evidence to tell us that these drugs worsen the risk of getting COVID-19 or the consequences once infected (see a statement from Hypertension Canada from March 13th, 2020 here). If your doctor started one of these drugs to protect your heart or kidneys you should keep taking it, unless you have diarrhea, vomiting, or are dehydrated, in which case consult your healthcare team for advice.
Q: How about ibuprofen?
Despite some suggestions in the media that ibuprofen should be avoided with COVID-19, as of yet there is no evidence to suggest it is unsafe, although some health authorities (such as the NHS in the UK) are recommending acetaminophen as a first choice to treat a fever with suspected COVID-19. However, for anyone that takes ibuprofen for other conditions (such as arthritis), there is no need to stop at this time. Patients with advanced kidney damage should be cautious about using ibuprofen in general and this situation also applies to the current situation. Some CGM sensors (including Dexcom G4 and G5, Medtronic Enlite, and possibly others) are affected by acetaminophen and cause the sensor to show a higher reading than the true blood glucose level over the 3-4 hours after taking a typical dose. Thus, if you use one of these sensors and suspect you may have COVID-19, we encourage you to use a back-up glucose monitoring method (fingersticks) if taking acetaminophen.
Q: How can I support my family in learning about and preparing for COVID-19?
Families must find appropriate ways to speak to their children about the pandemic and teach or reinforce important health behaviours that lower risk of exposure. Each family must find their own solutions to adapt to restrictions such as social distancing or quarantine. A helpful resource can be found here.
Q: Should I avoid attending in-person medical appointments right now?
It’s best to contact your local healthcare team for advice. Many clinics are offering appointments by phone or video call to minimize the risk of contracting COVID-19, as well as delaying routine lab work. Rest assured, if there is an urgency to be seen, your teams will be able to see you. It is just not wise to have large groups of people congregating at health care facilities right now.
For additional information on preventing COVID-19, being prepared, and what to do if you think you might have symptoms of COVID-19, please visit jdrf.ca/coronavirus.
We sincerely thank Dr. Farid Mahmud (Associate Professor, Pediatrics, Endocrinology, Hospital for Sick Children), Dr. Remi Rabasa-Lhoret (Professor of Medicine and Nutrition at the L’Institut de recherches cliniques de Montréal (IRCM) and Le Centre hospitalier de l’université de Montréal (CHUM)), Dr. Bruce Perkins (Professor of Medicine, Endocrinology, University of Toronto), and Dr. Peter Senior (Professor of Medicine, Division of Endocrinology, University of Alberta) for offering insights.