COVID-19 and Endocrine Diseases: Supportive Statement from the ESE

The coronavirus disease 2019 (COVID-19) outbreak requires endocrinologists to advance even further to the front lines of patient care, in collaboration with other physicians such as those in internal medicine and emergency units. This will preserve health status and avoid adverse outcomes related to COVID-19 in people affected by different endocrine diseases.

People with diabetes in particular are among those at high risk, who can develop severe illness if they contract the virus, according to data released so far from Chinese researchers. But also, patients with other endocrine diseases such as obesity and adrenal insufficiency can be affected by COVID-19.

Furthermore, endocrinologists, like any other health worker in the context of the current COVID-19 outbreak, will have to protect themselves from this viral disease, which is proving to have a very high capacity for spread and devastation. We urge health authorities to provide adequate protection to the entire healthcare professional workforce and to constantly test exposed personnel for COVID-19.

A decrease in the number of professionals is a threat to the health system and the well-being of patients.

Symptoms of COVID-19 infection

General symptoms are relatively nonspecific and similar to other common viral infections targeting the respiratory system, and include fever, cough, myalgia, and difficulty breathing. The clinical spectrum of the virus ranges from mild illnesses with nonspecific signs and symptoms of acute respiratory illness, to severe pneumonia with respiratory failure and septic shock.

Possibly, an excessive reaction of the immune system leading to autoimmune aggression of the lungs could be involved in the most severe cases of acute respiratory distress syndrome.

Cases of asymptomatic infection have also been reported and research in this matter is currently ongoing worldwide to clarify the true prevalence of the disease and the true relative mortality rate.

COVID-19 infection and diabetes mellitus

> Increased risk of morbidity and mortality in patients with diabetes with respect to COVID-19 infection

Older adults and those with serious chronic illnesses such as heart disease, lung disease, and diabetes are at highest risk for complications from COVID-19 infection.

Chronic hyperglycemia negatively affects immune function and increases the risk of morbidity and mortality due to any infection and is associated with organic complications . This is also the case with COVID-19 infection.

Among mortality cases in Wuhan, China, the main associated comorbidities included hypertension (53.8%), diabetes (42.3%), previous heart disease (19.2%), and cerebral infarction (15.4%).

Furthermore, new data regarding COVID-19 indicate that infection potentiates myocardial damage and identifies underlying cardiac disorders as a new risk factor for serious complications and worse prognosis.

Among confirmed cases of COVID-19 in China before February 11, 2020, the overall reported mortality is 2.3%. These data refer mainly to hospitalized patients. Among people without underlying medical conditions, the reported mortality in China is 0.9%.

Data on the number of non-symptomatic cases is lacking , as universal microbiological testing has not been performed in most countries. It is presumed that the prevalence of infection is probably high or very high in the community, leading to an overestimation of the prevalence of death in case. However, mortality increases strongly with the presence of comorbid diseases.

Among people aged 60 years and older , mortality has been reported to be 14.8% in those >80 years of age, 8% for those aged 70 to 79 years, and 3.6% in those aged 60 years or older. at 69 years old.

Compared with non-ICU patients, critically ill patients are older (median 66 years vs. 51 years) and have more prior comorbidities (72% vs. 37%).

> What people with diabetes should do to prevent COVID-19 infection

Social distancing , as well as home isolation of the entire population, have been widely adopted in many countries around the world as hopefully effective measures against the spread of infection.

We recommend that people with diabetes strictly adhere to these preventive measures and also adopt them within their homes to avoid being in contact with their family members.

 It is important to maintain good glycemic control as it could help reduce the risk of infection itself and may also modulate the severity of the clinical expression of the disease.

Contact with healthcare professionals, such as endocrinologists in the case of type 1 diabetes, and also including internal medicine specialists and general practitioners for patients with type 2 diabetes, may be advisable.

However, routine visits are not recommended for people with diabetes as they should avoid crowds (waiting rooms). Therefore, we recommend phone calls, video calls and emails as the primary form of contact.

Additionally, it is recommended to ensure an adequate stock of blood glucose control medications and supplies during the home isolation period.

> What people with diabetes should do if they are infected with COVID-19

People with diabetes infected with COVID-19 may experience deterioration in glycemic control during the illness, as in any other infectious episode.

Contact your doctor in case of possible symptoms of COVID-19 infection in order to seek advice on measures to avoid the risk of deterioration of diabetes control or the possibility of being referred to another specialist (pulmonologist, infectious disease specialist) or to the emergency service of the referral hospital to avoid serious systemic complications.

COVID-19 and other endocrine and metabolic disorders

> Obesity

There is a general lack of data on the impact of COVID -19 on people suffering from obesity. However, in some hospitals in Spain, cases of young people with severe obesity can progress to destructive alveolitis with respiratory failure and death.

There is no current explanation for this clinical presentation, although it is well known that severe obesity is associated with sleep apnea syndrome, as well as surfactant dysfunction, which may contribute to a worse scenario in the case of COVID infection. -19.

Furthermore, impaired glycemic control is associated with impaired ventilatory function and may therefore contribute to a worse prognosis in these patients.

On the other hand, type 2 diabetes and obesity can coincide, usually in patients aged >65 years. In summary, these patients may be at increased risk of deterioration in the case of COVID-19 infection.

> Malnutrition

Regarding malnourished subjects, COVID-19 infection is associated with a high risk of developing malnutrition, mainly related to increased nutritional requirements and the presence of a severe acute inflammatory state. These patients also show hyporexia, thus contributing to a negative nutritional balance.

A nutrient-dense diet is recommended in hospitalized cases, including high protein supplements (2-3 intakes per day) containing at least 18 g of protein per intake.

Adequate vitamin D supplementation is recommended, especially in areas with known high prevalence of hypovitaminosis D or due to decreased sun exposure.

If nutritional requirements are not met, complementary or complete enteral feeding may be necessary, and in case enteral feeding is not possible due to gastrointestinal intolerance, the patient should be placed on parenteral nutrition. The outcome of COVID-19 patients is expected to improve with nutritional support.

> Adrenal insufficiency

Adrenal insufficiency is a chronic condition of lack of cortisol production. Replacement treatment is not easy for these patients. Based on current data, there is no evidence that patients with adrenal insufficiency are at increased risk of contracting COVID-19.

However, patients with Addison’s disease (primary adrenal insufficiency) and congenital adrenal hyperplasia are known to have a slightly increased overall risk of infections.

Primary adrenal insufficiency is associated with impaired natural immune function with defective action of neutrophils and natural killer cells .

This may explain, in part, this slight increase in the rate of infectious diseases in these patients, as well as an overall increase in mortality. The latter could also be accounted for by an insufficient compensatory increase in the hydrocortisone dose at the time of the beginning of an infection episode.

For all of these reasons, patients with adrenal insufficiency may be at increased risk of medical complications and ultimately at increased risk of mortality in the case of COVID-19 infection. So far, no data have been reported on the outcomes of COVID-19 infection in these patients.

In case of suspicion of COVID-19, a prompt modification of replacement treatment should be established. This means in the first instance at least doubling the usual glucocorticoid replacement doses, to avoid adrenal crisis.

In addition, patients are also advised to have sufficient stock of steroid pills and injections at home in order to maintain the social isolation that is required in most countries to prevent the spread of the COVID-19 outbreak.

Measures to take if COVID-19 infection is suspected

If a person with endocrine and metabolic diseases has a fever with cough or difficulty breathing and may have been exposed to COVID-19, a call should be made to the doctor for advice. Some countries have established telephone lines for the public.

The staff in charge of these telephone lines will inform you what the next step should be in the medical care protocol. If the person is recommended to go to the hospital, the use of a face mask or chinstrap is recommended.

In countries with an explosive outbreak, most people have already purchased masks on their own initiative. Fluid samples taken from the nose or throat will be used for microbiological diagnosis. There is currently no specific treatment for COVID-19, but since most cases are mild, only a limited number of people will require hospitalization for supportive care.

However, in most countries where the outbreak has been declared and recognized, particularly China, the northern regions of Italy, Iran and Spain, the situation has been very difficult and the need for hospitalization has led to national health systems at the limit of their capacities.

What to do in case of isolation at home?

Individuals and families affected or suspected of being affected by COVID-19 who stay at home should follow appropriate infection prevention and control measures. Management should focus on preventing transmission to others and monitoring clinical deterioration, which may lead to hospitalization.

Affected people should be placed in a well-ventilated single room, while household members should stay in a different room or, if that is not possible, maintain a distance of at least one meter from the affected person (e.g. sleeping in a separate bed) and perform hand hygiene (washing hands with soap and water) after any type of contact with the affected person or their immediate environment.

When washing your hands, it is preferable to use disposable paper towels to dry them. If not available, clean cloth towels should be used and replaced when wet.

To contain respiratory secretions, a face mask should be provided to the affected person. People who cannot tolerate a mask should use rigorous respiratory hygiene, that is, covering the mouth and nose with a disposable tissue when coughing or sneezing.

Caregivers should also wear a tight-fitting mask that covers the mouth and nose when present in the same room as the affected person.