Taking a first look at COVID-19’s effects on children and adolescents with Type 1 diabetes (T1D), researchers have linked ethnic minority status, poor blood-sugar control and diabetic ketoacidosis (DKA) with increased hospitalization.
The connection between Type 2 diabetes (T2D) and severe COVID-19 has been well established, with the more common T2D a clear risk factor for poorer outcomes and death from SARS-CoV-2. Few studies have focused on T1D, however, and none has zeroed in on pediatric patients until now.
The Barbara Davis Center for Diabetes (BDC) at the University of Colorado Anschutz Medical Campus took part in the multicenter study, spearheaded by the Boston-based T1D Exchange Quality Improvement Collaborative. The study was published online this month in the Journal of Diabetes.
DKA, COVID-19 can equal trouble
In patients with T1D, the pancreas produces little to no insulin, blocking glucose (blood sugar) from entering cells for life-sustaining energy. Most often diagnosed in children and adolescents, patients face a life-long battle of maintaining that critical blood-sugar balance.
DKA sets in when the balance becomes so out of whack, acids called ketones build up in the blood. “It leads to dehydration and vomiting, and, if left untreated, the patient will die,” said the BDC’s G. Todd Alonso, MD, associate professor of pediatrics at the CU School of Medicine and lead author of the study.
While researchers didn’t find T1D itself putting the young patients more at risk for severe COVID-19 illness than their non-diabetic peers, they did discover that DKA and COVID-19 was a dangerous mix.
“DKA was largely what put the kids in the hospital,” Alonso said of the study participants. “It wasn’t something novel with the coronavirus, yet you can imagine that these are two things that you don’t want to have together.”
High blood sugar, ethnicity raise risk
The study assessed risk factors and outcomes in 266 patients with confirmed COVID-19. All participants were 18 or younger with T1D. Comparisons were made between hospitalized and non-hospitalized cases.
Looking at their last A1c results (a blood test that shows median blood sugar levels over a three-month period), researchers found that 86% of patients in the study with DKA had levels above 9% with an 11% median. The A1c target for people with diabetes is below 7%. DKA was the most common adverse outcome, occurring significantly more often in the hospitalized group (72%).
“So, this is a group with very high baseline blood sugar,” Alonso said.
Hyperglycemia (high blood sugar) can also increase hypercoagulation risk (resulting in blood clots), as can COVID-19.
“Hyperglycemia (reported in a third of the cases) can lead to dehydration, and dehydration can lead to a state where you can form blood clots more easily,” Alonso said. “So, putting hyperglycemia with the known hypercoagulation risk from COVID-19 could be an especially dangerous combination.”
People of color also had increased risk of hospitalization. White children make up about 75% of all T1D pediatric cases in the United States, Alonso said. Yet, in the study, hospitalized patients were more likely than non-hospitalized patients to have minority race/ethnicity (67% vs. 39%).
“That just totally sets it on its head,” Alonso said. “This is consistent with other research showing that our communities of color are more severely affected by this pandemic.”
Other disparities underscored
Children who were hospitalized were also more likely to have public insurance (64% vs. 41%) and less likely to use insulin pumps (26% vs. 54%) and continuous glucose monitors (CGM) (39% vs. 75%) than their non-hospitalized peers.
Among the study patients, only 65 of 123 (53%) of those with public insurance were using CGM, compared to 113 of 138 (82%) of those with private insurance. In what Alonso called “a really big deal” for diabetes caregivers and patients, Colorado this month approved a CGM coverage policy for people with Medicaid insurance.
“This is consistent with other research showing that our communities of color are more severely affected by this pandemic." – G. Todd Alonso, MD
Access to healthcare, including glucose-management education and provider communication and guidance, are all critical to good diabetes care, Alonso said. Researchers suspect barriers to healthcare account, in part, to disparities the study found.
BDC answering the call
“We’ve really doubled down on emphasizing sick-day management and teaching our patients how to troubleshoot diabetes management,” Alonso said, adding that often requires being able to call an expert for help.
BDC provides doctor access 24/7. Through the patient portal, BDC patients also can receive a sick-day plan that is automized through their electronic medical record and based on age, weight and current insulin doses.
“It’s really concerning that we have populations of patients we don’t communicate with as well, and we need to find better ways to do that,” Alonso said. “When we do get those phone calls early on in illness (whether with DKA or COVID-19), we can usually help them manage their diabetes at home before they get really ill. But it takes a lot of troubleshooting.”
The study highlights the need for patients to call their doctors, especially during the pandemic, he said. “This really underscores how an illness like COVID-19 can push people with T1D over the edge. If it’s 2 in the morning, and you are throwing up, wake somebody up. Wake up one of our doctors, because that’s a call I really want to take.”