Sidelined or streamlined? Diabetic care and COVID-19
pharmafile | December 6, 2021 | Feature | Sales and Marketing |
The worldwide restrictions put in place as a result of COVID-19 have necessitated innovation in multiple medical spheres. Diabetes, which places individuals at a higher risk of coronavirus infection, and of complications associated with COVID-19, has posed a particular challenge for both patients and healthcare professionals. Those diagnosed with Type 2 diabetes are often not only more vulnerable to infections of many kinds, but also require hospitalisation for them more often, and in cases of COVID-19 related hospitalisations, diabetes was frequently associated with poor early outcomes for patients.
Diabetes as a high-risk condition
In fact, after hypertension, diabetes is the second most common comorbidity seen in people with the virus. Of diabetic patients hospitalised with COVID-19, 37.1% required mechanical ventilation, compared to 23.2% of hospitalised patients who did not have diabetes.1 Pharmafocus spoke to Novo Nordisk, a Denmark-based leading global healthcare company, for insights into the new difficulties presented to diabetic patients.
Stephen Gough, Senior Vice President and Chief Medical Officer at the company told us: “Whilst diabetes in itself does not appear to increase the risk of getting COVID-19, people with Type 1 or Type 2 diabetes are at much greater risk of a serious outcome if they contract COVID-19. This reflects how people with diabetes in general can suffer from a multitude of complications that exacerbate COVID-19, including hypertension, heart disease, and/or chronic kidney disease.”
15.9% of diabetic patients from intensive care unit data of 450 patients hospitalised with COVID-19 died due to COVID-related complications, compared to 7.9% of non-diabetic patients. These risks are accelerated in individuals with poorly controlled diabetes, and comorbidities. “The COVID-19 pandemic has reminded us that there is an often-neglected link between non-communicable conditions such as diabetes and communicable diseases, including COVID-19,” Gough continues. “Many infections, whether they are viral, bacterial, or parasitic, drive a large part of the morbidity and mortality faced by humans. Unfortunately, the realistic prediction is that the COVID-19 pandemic is not the last such challenge that humanity will face.”
Sidelined by the pandemic
Addressing the pandemic has become a priority for healthcare systems, meaning that the management of chronic conditions has often been neglected. With an estimated 463 million worldwide affected by diabetes, this is a significant discrepancy in treatment and accessibility – a problem already affected by the hindering role economics and geography can play in care and diagnosis. According to the International Diabetes Federation in 2019, of the 463 million people affected by diabetes, 232 million are undiagnosed, and unaware that they have the condition.2 Within the UK, 3.9 million have been diagnosed with diabetes as of 2019. Doctors believe, however, thousands more remain undiagnosed – and that this disparity has likely worsened during the pandemic.3
Considering the much higher risk COVID-19 has presented to diabetic patients, and the factors which amplify risk, including poverty and age, issues surrounding accessibility to treatment during a pandemic are compounded. In November World Diabetes Day was celebrated, the theme of which was ‘Access to Diabetes Care’. Millions worldwide are not able to access treatment, particularly in low-and middle-income countries. Those struggling to obtain access to insulin, however, includes many in the US today.
Effect on Worldwide insulin access
2021 celebrates 100 years since the invention of insulin, marking its isolation in 1921 and delivery to a 14-year-old in a diabetic coma in 1922. More innovations and developments in the treatment and management of diabetes accompany this anniversary, but more need to follow. In November 2019, WHO launched an insulin prequalification programme to expand access to insulin, aiming to encourage more insulin manufacturing and a lowering of costs. This programme saw the inclusion of genetically altered insulin, a longer lasting and rapid acting form of the drug, on the WHO Essential Medicines List. In spite of this, insulin today remains unaffordable for many.
Against such a backdrop, a pandemic is limiting access to care through factors such as social distancing and clinical trial delays, hindering research and development in improving care and access. Avideh Nazeri, Vice President of Clinical Development, Medical, and Regulatory Affairs at Novo Nordisk, shared with us: “With the global health agenda and health system capacity focused so closely on tackling the COVID-19 pandemic, support for people with chronic conditions like diabetes has taken a back seat. Most in-person appointments and routine care were initially postponed during lockdown, creating a backlog of care that we are still working our way through – and likely will be for many months to come.”
COVID-19 has drawn attention to the importance of access to healthcare by forcing individuals into isolation, by causing redundancies, and by heightening health risks for those already vulnerable to infection – those deemed ‘high risk’ includes individuals living with diabetes. This is an emerging problem, particularly if more pandemics arise. Nazeri continued: “Moving forwards, healthcare systems need to be equipped to address both COVID-19, as an endemic disease, and chronic diseases such as diabetes, which are increasing in prevalence.”
A new hope?
Responses to this include remote healthcare, for which numerous innovations have been made, for which the difficulties presented by COVID-19 have accelerated. Dexcom is seeking to facilitate remote management, developing technologies for continuous glucose monitoring (CGM), a small device measuring glucose levels continuously. John Welsh, MD, PhD, was diagnosed with Type 1 diabetes in 1976, and now manages medical writing efforts at Dexcom. He shared the impact of continuous glucose monitoring on his experience of diabetes with Pharmafocus:
“Managing diabetes is so much easier than it was just a few years ago, and tremendously easier than back in the 1970s when I was diagnosed with Type 1. To my mind, automated insulin delivery systems that have become widely available in the past five years have made diabetes management safer, less burdensome, and are very likely to improve long-term outcomes. Five years ago, the idea of CGM data to control insulin was just getting off the ground, and the only way you could automate was by stopping the pump in the face of low glucose. Nowadays I can go for large parts of the day without giving my diabetes a second thought, thanks to algorithms that increase or decrease my insulin delivery automatically.”
Developments in diabetes management continue, then, in spite of restrictions imposed by coronavirus. COVID-19 has, further, forced innovations: “In many cases, the COVID-19 pandemic has fast-tracked the adoption of digital innovations in diabetes – which I believe are here to stay,” Nazeri added. “Digital innovations such as telehealth not only offer a way to provide remote care, but also have the potential to make it easier for people to manage their diabetes, reducing the mental and physical burden of living with the condition every day.”
Attempts to personalise diabetes care, allowing for categorisation of subpopulations on the basis of biological and genetic variables, are increasing in frequency. This personalisation will allow for the identification of clusters of people with different characteristics and risks of diabetes, who could be responsive to targeted therapeutic interventions. Research has shown that beyond Type 1, Type 2, and gestational diabetes, there are a range of diabetes types including Wolfram syndrome, Alström syndrome, and cystic fibrosis diabetes.2 Categorising by another system, there are five genetically distinct clusters of diabetes including insulin-deficient diabetes, and insulin-resistant diabetes.
Categorising diabetes with more specificity allows for more personalised, targeted, and potentially effective treatments. Welsh shared insights with us on the important role more individualised treatments can play, particularly during a pandemic: “Insights from CGM data can be used to assess the adequacy of glycemic control for individuals through metrics such as time spent in target glucose range. With wider CGM adoption, HnA1c [average blood glucose levels for the past two-three months] and SMBG [self-monitoring of blood glucose] may soon become legacy tests for diagnosing and managing diabetes.” On this front, Dexcom work in developing technologies for CGM to manage diabetes on a less intense and intrusive scale than standard management of the condition.
Welsh continued: “Changes have very much been accelerated by the pandemic, largely when it comes to wider adoption of telehealth practices. In-person consultations became difficult during the pandemic so the number of doctor visits occurring remotely sharply increased. Real-time CGM can make the process of transitioning to telemedicine significantly more seamless for providers and patients with diabetes.”
Lockdowns necessitated social distancing, which had huge implications for those suffering chronic conditions. Drawbacks included a decrease in patient and doctor satisfaction, and concerns over slower diagnosis and care due to a lack of face-to-face contact. However, being forced into remote care so suddenly also necessitated digital innovation. Welsh added: “One of the biggest things to come out of the first lockdown was the fact that it accelerated the NHS’s Five-Year Forward View plan to digitise. Digitisation helps relieve pressure on hospitals, staff and patients as it allows for remote treatment, and greater accuracy since remote treatments are often smart, electronic devices.” For patients with chronic conditions, particularly patients with multiple diagnoses, digital healthcare can be of enormous benefit in reducing healthcare visits and exposure to high-risk areas during a pandemic.
With digital healthcare potentially improving accessibility, and WHO’s legislative attempts to improve patient access to insulin, steps towards more universal diabetes management are being made. These are, however, steps in the management of diabetes, and not a cure. Access to insulin is a persisting issue for half of the global population suffering the disease, and only one in seven people with diabetes in Africa able to access the drug. The stark unmet patient needs in people suffering diabetes continue, exacerbated by the conditions of COVID-19.3
However, Dr James Shapiro, Canada Research Chair in Transplant Surgery and Regenerative Medicine at the University of Alberta, is working in stem cells in the hope to see a specialised therapy which could be distributed on a global scale. The impact of this treatment would be immense, potentially curing one of the most prevalent non-communicable diseases (NCDs) of our time. As a result, the efforts of the research are vast, encompassing a team of engineers, robotic engineers, experts in AI, machine learning, and experts in stem cells.
He spoke to our sister magazine ICT in an interview, about his work as we approach the anniversary of insulin’s discovery and delivery: “Obviously, we’re celebrating 100 years from 1922 to 2022. When we reach that point we’re hoping for something better than insulin, and we really believe that the stem cell autologous type approach will prove just that.”
1. Sieglie J, Diabetes as a Risk Factor for Poor Early Outcomes in Patients Hospitalised with COVID-19, Diabetes Care, 43(12): pp2,938-2,944, 2020
2. Visit: www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html
4. Visit: www.diabetes.org.uk/diabetes-the-basics/other-types-of-diabetes
5. Beran D, Mirza Z, and Dong J, Access to insulin: applying the concept of security of supply to medicines, Bull World Health Organ, 97(5): pp358-364, 2019