Rapid rise in insulin requirements of inpatients with covid-19 given dexamethasone: Adaptations of the national guidelines to local needs

Background: Dexamethasone is being increasingly used in the treatment of covid-19 pneumonitis, leading to hyperglycaemia in patients both with and without diabetes. Pandemic related capacity issues are causing inpatient diabetes teams to become stretched with facilitating early supported discharges, where steroid induced hyperglycaemia requiring insulin has occurred. Protocolised solutions are therefore required to counter this problem. Aims: To design a de-escalation pathway using an objective means (HbA1c) to guide non-specialist teams with the management of anti-hyperglycaemic agents initiated during admission for covid-19 pneumonitis and follow-up requirements. Methods: Patients with covid-19 infection on dexamethasone referred to the inpatient diabetes team over a 2-week period were subcategorised using HbA1c values, to determine the need for ongoing insulin therapy and appropriate follow-up. Results: Of 121 referrals, dexamethasone was initiated in 95% of cases leading to steroid induced hyperglycaemia. HbA1c was measured in 61 cases. Only three cases had HbA1c values below the 48 mmol/mol cut-off. These were considered low-risk and suitable for GP follow-up. However, 38 cases (62%) had HbA1c values greater than 70 mmol/ mol and thus required insulin therapy on discharge, intensive glucose monitoring and specialist follow-up at 48 hours post-discharge. Conclusion: We suggest measuring HbA1c at the point of admission for all patients presenting with suspected covid- 19 infection. Where electronic phlebotomy requests exist, covid-19 admission bundles which include HbA1c may be helpful. HbA1c values can serve as a tool to provide non-specialist teams with a diabetes care plan on how to de-escalate insulin therapy, glucose monitoring requirements and advise on appropriate follow-up. Review of readmission/ harm is currently ongoing.