Elderly with Diabetes and Hypertension

Greater Kashmir

What is Covid?

Corona virus (single stranded RNA belonging to Corona viridae family) named in view of its characteristic appearance (halo of sun) has assumed the highest popularity in the human history with 18,41,00,00,000 citations on google. It started with unidentified after exposure to wet markets in Wuhan, China in December 2109.  Over the past two decades two other similar and highly pathogenic novel zoonotic Corona virus disorders namely Severe Acute Respiratory Syndrome (SARS-CO-1) in Nov 2002 and Middle East Respiratory syndrome (MERS-COV-1) in June2012 were reported.

Being a novel disease little is known about pathophysiology, modes of transmission, preventive and treatment strategies. What is known is that COVID 19 binds to the ACE 2 receptor (mainly found in lower respiratory tract, heart, kidneys and brain) and enters in to human cells where the virus replicates by taking control of the host cell. The relation to ACE 2 receptor ad relation to pulmonary vasculature (lung blood vessels) is hypothesized to cause acute respiratory distress in the Covid Pneumonia.  The disorder has spectrum of clinical manifestations is mild in 80% and moderate to severe (around 5% critical).  in the rest depending on AGE (>65 years) or existing disease conditions such as Diabetes or Hypertension (high BP) or Heart/Lung disease.

What is global burden and why the alarm?

Covid 19 kept on spreading since December across continents and was WHO in February 2020 declared it ‘’Pandemic ‘’ and 6th  Public Health emergency of international concern. Covid 19 is highly transmissible especially through asymptomatic carriers (super spreaders).  While writing this piece 488,289 active cases (81,285 China, 74, 386 Italy and 68,594 USA)  are reported worldwide with 22,069 deaths.  Italy is leading in the death toll (7503) followed Spain (4089) and China (3287). India has 716 cases with 14 deaths out of which 20 cases are from J& K. Kashmir reported its first death of 65 year old male who had diabetes and hypertension.

How does covid 19  present?

There is plethora of information available on symtomology and precautions to be observed for Covid prevention. We should laud the efforts of health sector and the media who are playing a significant role in this regard. Briefly saying majority of subjects have no symptoms or have mild symptoms that can easily be confused with common flu. Among those who have symptoms high grade fever, running nose, cough associated with respiratory distress, chest discomfort, fatigue, myalgias, abdominal pain, diarrhea. The commonality of symptom reported from Wuhan or S Korea are fever (91.7%), cough (75%), fatigue (75%) and gut symptoms (39.6%) being reported in the COVID positive patients.

What are its modes of spread?

The most common mode of transmission is person to person via droplets. It stays in air for 3 hours, on steel and plastics for days and on copper for just 1 hour. Community transmission of the virus is very high, so in order to prevent the infection from the infected persons social gatherings should be avoided,  social distancing , frequent washing if hands with soap for at least 20 seconds, proper sanitization is very important to break the chain of spread.  All the people who have travel history from the infected country should be quarantined for 14 days, as per the recent ICMR guidelines all the close contacts of the person should be quarantined and checked to prevent the transmission of the virus and to contain it, and if any of the  COVID-19 positive contacts develop fever or any other associated symptoms related to infection should be tested.

What is Diabetes mellitus ?

Diabetes mellitus or (high blood sugar) is a widespread and rapidly increasing condition where glucose levels (normal feul for day to day energy) cross its upper limit (126 mg/dl in fasting state) of normal. This high glucose level ends up damaging most of the body tissues mainly blood vessels in heart, kidneys, eyes, feet.  This leads to very high morbidity (handicaps) and mortality (death) among populations if not taken care.

What is the burden of Diabetes in the community?

According to 2020 IDF (International Federation of Diabetes) ATLAS 1 in 11 adults has diabetes (455 million) and 12% of global health expenditure is spent on diabetes Three quarters of people with diabetes live in low and middle income countries. In India 79,203 million of people are supposed to be affected and the disease is galloping crossing the initial projections as per latest studies including ICMR-INDIAB Study.

How does COVID -19 affect Diabetics?

Diabetes is considered as an immuno-supressed state and even though scientific proof is lacking they may be more susceptible. International Diabetes Federation (IDF) recommends that people with diabetes plan ahead of time what to do before they get ill. This includes having the contact information of their treating doctor at hand and making sure to have an adequate stock of medications and supplies for monitoring blood glucose at home, so that they do not need to leave the house if they become ill. In case of infection with Covid 19 diabetics may see their glycaemic control deteriorating and they should follow the “Sick day rules” generally recommended for any stressful situation. They should not panic but should contact their health care provider for advice on how to monitor their blood glucose, get adequate refills for medications (especially insulin) and what adjustments they may need to do in their medication or diet.

  • Sick day rules for people with diabetes
  • Keep themselves well hydrated (take adequate water)
  • Monitor blood glucose regularly
  • Monitor body temperature
  • If type 1 diabetes on insulin, may check urine ketones

Why is Covid 19 relevant to Diabetics?

Although there is more risk of mortality in elderly, pregnant and immune-compromised subjects but data from countries who have recently undergone spikes of infection showed severe disease among subjects with preexisting diabetes or hypertension. In a retrospective study done in Wuhan in the patients who had contracted the virus and were admitted in the hospital , it was found that 48% of the deaths were associated with hypertension as a comorbidities, followed by diabetes which was 19% and CVD 8% followed by lung diseases, cancers etc. ACE 2 gene polymorphism that has been linked to diabetes and hypertension in Asian population creates a possibility that patients with these comorbid diseases are at a higher risk of COVID 19, as compared with the healthy population.

How can you harmonise care of people with diabetes?

In response to government administered lockdown in the country to curb the community spread of COVID-19 pandemic, diabetic subjects have restricted movement and are likely to missed routine exercise protocol. Since regular physical activity is of great benefit to the general population and even more for people living with diabetes. This unprecedented lockdown along with scary statistics in news is going to add to the already existing burden of psychiatric comorbidities. Hence there has to be tailor made programme of exercise schedule according to home environments while maintain hygiene and social distancing. Building their morale with frequent telephonic conversations, showing optimism, avoiding panic and even discussion with a psychotherapist may go a long way in avoiding problems. NGO or self help groups should play their role in the hour of need.

How does COVID 19 affect patients with high blood pressure?

Because of the weakened immunity in the patients with Diabetes, they are at a higher risk as compared to non diabetics. Diabetics should pay attention to there blood sugars, as diabetics are more prone to Diabetic ketoacidosis with COVID 19.  A recent study on 2000 admitted patients in hospital it was found that Blood group A are more susceptible to COVID-19.  A recent debate on as COVID-19 gets attached to ACE-2 receptors safety of ACE inhibitors/ ARBs in patients who are already on these drugs was speculated, but AHA (American Heart a Association) recommended to continue the medications of patients with hypertension /cardiovascular disease (CVD) and heart failure.  Hypertension is the most common comorbidity in Covid 19 patients and may have higher risk of complications. These subjects need to continue antihypertensive medications and healthy life practices (daily walk 30 minutes in your courtyard and low salt diet). In case of any breathlessness, you may contact your treating doctor. You should remain under stringent vigilance of healthcare workers especially by telephone. Panic rushing to hospital should be avoided.  Self ambulatory blood pressure monitoring if possible, can be very useful.

How does COVID -19 affect Elderly?

With epidemiological trends in the country there is significant proportion of population of elderly in India and the valley. World Health Organization (WHO) have identified elderly people as especially vulnerable to Covid-19 as lessons from the Chinese outbreaks have shown  more fatal cases among elderly people. This is attributed to existing health problems such as those of lungs, heart, kidney or diabetes or cancer. Fortunately in our valley as in most parts of the country most of elderly live in joint families paving a way for their care and avoiding isolation during lockdown. But the downside of living in joint families is that elderly may get infected through an asymptomatic family member like a child. Thus, you need to keep them in separate rooms even in the house and when you visit elderly people, maintain a two-metre distance. Also do not forget to wash your hands with a soap or use of alcohol-based hand sanitiser before you touch them or their fomites. The Care-Givers have to be vigilant for any minutest symptoms as elderly are known to show less symptoms till in the disease process in general.

Is there any vaccine available for Covid?

Since Covid is a novel (first time seen affecting humans) virus no vaccine is available unlike other flu virus disorders. First vaccine (mRNA-1273) has been given to 45 volunteers aged 18-55, results of which are much waited by the whole world. However, attempts by researchers are underway for the same. At this moment best vaccine is prevention of contact from other fellow humans.

Are there any drugs available for COVID-19 prevention or treatment ?

For prevention The National Taskforce for COVID-19 by ICMR recently recommended  the use of hydroxy-chloroquine (HCQS) for prophylaxis in : asymptomatic healthcare workers caring Covid cases or asymptomatic household contacts of laboratory confirmed cases. It may be noted that HCQS is already in Indian market as add-on therapy for type 2 diabetes.  HCQs 400 mg twice a day on Day 1, followed by 400 mg once weekly for next 3 weeks; to be taken with meals Exclusion/contraindications. The drug is not recommended for prophylaxis in children under 15 years of age, cases of retinopathy, known hypersensitivity to hydroxychloroquine, 4-aminoquinoline compounds. It has to be prescribed by a registered medical practitioner.

According to the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and the U.S. Food and Drug Administration (FDA), there are currently no medications or vaccines proven to be effective for the treatment or prevention of the 2019 severe acute respiratory syndrome coronavirus 2. China International Exchange and Promotive Association for Medical and Health Care (CPAM) recommends use of lopinavir; ritonavir [2 capsule (dose undefined) by mouth twice daily] in combination with nebulized alfa-interferon (5 million units in Sterile Water for Injection inhaled twice daily). Sofosbuvir in combination with ribavirin is also potential agent.  WHO is going to start a intervention trial (SOLIDARITY Trial) at multiple center by this weekend whereby antiviral drugs like Remdesivir combination of  Lopinavir  and Ritonavir with or with Inf-Gamma and Hydroxychloroquine (HCQS).

Prof Mohammad Ashraf Ganie, Endocrinology and Metabolism SKIMS Srinagar