COVID-19 May Trigger New-Onset Diabetes

With Orville Kolterman MD

Not only does COVID-19 have the ability to worsen existing diabetes, a recent report found that the virus may be triggering new-onset diabetes.

The information we have about COVID-19 changes just about every day, leading to both more unanswered questions as well as more knowledge about staying safe and maximizing recovery.

It was originally understood that COVID-19, a Coronavirus, was found to pose the most risk to the elderly and people with pre-existing medical conditions. These included high blood pressure, lung disease, heart disease, cancer, or diabetes. New data has led to more specifics around those conditions, including diabetes.

Diabetes is a family of diseases that can lead to increased sugar in the blood (this is referred to as high blood glucose). Without diabetes, the body ensures that glucose enters the cells and is used for energy, rather than built up in the bloodstream. It does so with the use of insulin. But this isn’t the case with diabetes.

In type 1 diabetes, the immune system attacks the pancreas’ insulin-producing cells, resulting in the body not having enough insulin. In type 2 diabetes, the most common form of diabetes, the body doesn’t know how to appropriately use or make enough insulin. This means that insulin isn’t effectively moving the glucose into the cells — which leads to a build-up of glucose in the blood.

A change in COVID-19 risk warnings for diabetes

As of this month, the Centers for Disease Control has updated their information regarding COVID-19 risk warnings, which now include more specific data around diabetes. Specifically, the CDC now says people with type 2 diabetes are at an increased risk of severe illness from COVID-19 while people with type 1 diabetes or gestational diabetes might be at an increased risk for severe illness from COVID-19.

It’s important to note that having diabetes itself doesn’t increase the risk of catching COVID-19. Rather, diabetes increases the risk of complications and death if COVID-19 is contracted.

COVID-19 may trigger new-onset diabetes

Not only does COVID-19 have the ability to worsen existing diabetes, a new report published in Nature found that the virus may be triggering new-onset diabetes.

How so? It’s believed that the virus damages certain kinds of cells — known as beta cells — that are found in the pancreas. They are found within another kind of cell known as an islet cell (more on islet cells below). 

The destruction of these beta cells prevent the body from making insulin — triggering hyperglycemia (or high blood sugar). Because, in this case, the body needs glucose as energy (but can’t use it), it turns to ketones, chemicals the liver makes when you don’t have enough insulin, for energy. The use of ketones signals the production of acids, which can also lead to a condition called diabetic ketoacidosis (DKA), a potentially-fatal condition (more on symptoms below).

People with prediabetes who have been infected with COVID-19 should also be aware of the general symptoms of diabetes, according to endocrinologist Orville Kolterman MD. He explains that people with prediabetes should know that any added stress (such as a virus) can tax the metabolic system, which could lead to diabetes.

“Hypothetically, someone with prediabetes could get COVID-19 and be asymptomatic…but might experience the classic symptoms of the onset of diabetes,” Dr. Kolterman says. “The three Ps of diabetes are polyuria, polydipsia, and polyphagia.” They are, respectively, increased urination, increased thirst, and increased appetite.

Nature outlined one case of an 18-year-old in Germany named Finn Gnadt. Gnadt had been infected with COVID-19 (but felt fine), only later to develop type 1 diabetes. His symptoms? Fatigue and extreme thirst, leading his physician to connect his diagnosis back to COVID-19.

Beyond Gnadt, a number of other patients were found to have spontaneously developed diabetes after having been infected with COVID-19. This development of diabetes also occurred due to the SARS virus.

“We need to keep an eye on diabetes rates in those with prior COVID-19, and determine if rates go up over and above expected levels,”  Naveed Sattar, a metabolic-disease researcher at the University of Glasgow, UK, told Nature.

One way they’re trying to establish a definitive connection? A global database has been set up by an international group of scientists to obtain information from people (without a history of diabetes or blood sugar issues) with COVID-19 and newly-identified high blood-sugar levels. Beyond investigating the specifics of how the virus triggers diabetes, the researchers also trying to determine whether the diabetes cases are permanent.

COVID-19 can also worsen current diabetes

New data — found by comparing COVID-19 to SARS — has shown that COVID-19 can also worsen existing endocrine conditions, including diabetes.

So, how does it work? The virus binds to a receptor known as ACE2, which allows it to enter into endocrine cells. Once the virus takes hold, it can disrupt insulin production and cause blood glucose levels to go haywire, making it harder to fight off the virus.

According to The Endocrine Society, it all goes back to those islet cells mentioned above: “A study during the SARS epidemic demonstrated ACE2 expression in islet cells and a high incidence of hyperglycemia among SARS patients. The authors speculated that SARS-CoV-1 may directly infect islet cells causing their dysfunction, resulting in hyperglycemia or new-onset diabetes.”

But what are islet cells? Islet cells are found within the pancreas. Some of them produce hormones such as glucagon, which raises glucose levels in the blood.

Additionally, viral infections can lead to dysfunctional immune response and circulatory issues, as well as increased inflammation (which is also known as internal swelling) in patients with diabetes. This is due to high blood sugar, which can lead to further complications, according to the American Diabetes Association (ADA).

Dr. Kolterman says the majority of diabetes patients already have an inflammatory state present, “so if they become infected with COVID-19, the virus can create an inflammatory storm with cytokines flying all over the place.” This is known as a cytokine storm, which is an increase in cell-signaling proteins that create inflammation and can lead to organ failure or even death.

Some researchers also believe that an inflammatory state could lead to the development of new-onset diabetes as well, according to Nature.

Other risks to current diabetics? Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, both of which can be brought on by infection. These risks are high for patients who don’t have well-controlled diabetes, according to a study published in Diabetes and Metabolism Journal.

Diabetic ketoacidosis can also alter your electrolyte and fluid levels, which can be dangerous if sepsis —otherwise known as a life-threatening organ dysfunction due to infection — sets in. The ADA recommends checking for ketones (chemicals from ketoacidosis) if your blood sugar has registered high (greater than 240 mg/dl) more than twice in a row.

Symptoms of DKA include

  • Increased thirst
  • Bad (or fruity) breath
  • Nausea
  • Abdominal pain
  • Fatigue
  • Confusion

Another serious complication of COVID-19 and diabetes is called hyperosmolar hyperglycemic syndrome. It occurs when blood glucose is extremely high for a long period of time without intervention. The symptoms are similar to DKA, and include frequent urination and vision changes as well.

What to do if you have diabetes and contract or suspect COVID-19

Dr. Kolterman says that sheltering in place inherently makes things a bit more tricky: “Someone with diabetes needs a stockpile of diabetes paraphernalia. These patients should never run out of glucose control medications during this pandemic.”

He also says that people with diabetes who have or suspect COVID-19 and who are not seriously ill should, “double down on controlling glucose – and if they were to see that their glucoses were escalating, get in touch with their healthcare provider.”

Information to have ready when you call your doctor about your diabetes and COVID-19

  • Your glucose reading
  • Your ketone reading
  • Your COVID symptoms
  • How much fluid you’ve consumed
  • Information on your medications and insulin usage

If you have diabetes and suspect COVID-19, it’s important that you know the signs and symptoms of ketoacidosis and hyperosmolar hyperglycemic syndrome — and that you contact your doctor immediately if you experience them.

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