Table 1 Summary of Covid-19 recommendations for glucose-lowering drugs in the management of type 2 diabetes
From: The management of type 2 diabetes before, during and after Covid-19 infection: what is the evidence?
Publication | Metformin | SGLT2 inhibitors | GLP-1 RA | DPP-4 inhibitors | Insulin |
|---|---|---|---|---|---|
Bornstein [21] April 2020 | If patients are dehydrated, discontinue and follow sick day rules, due to risk of dehydration and lactic acidosis; monitor for chronic kidney disease or AKI | During illness, patients should stop taking the drugs and follow sick day rules, due to risk of dehydration and DKA; avoid initiating during respiratory illness; monitor for AKI | Dehydration should be closely monitored, and adequate fluid intake and regular meals encouraged | Can be continued, as generally well tolerated | Should be continued, with regular self-monitoring or CGM encouraged; early intravenous insulin therapy in severe courses (ARDS, hyperinflammation) |
Katulanda [18] May 2020 | Discontinue in severely ill patients with haemodynamic instability or hypoxia | Discontinue in patients where oral intake is not tolerated or who are severely ill | Discontinue in severely ill patients | May be continued in non-critically ill patients | Preferred treatment option in critically ill patients |
Hartmann-Boyce [19] June 2020 | Follow sick day rules and stop during acute illness | Follow sick day rules and stop during acute illness | Preferred treatment option in hospitalized patients, together with DPP-4 inhibitors and insulin | Preferred treatment option in hospitalized patients, together with insulin and GLP-1 RA | Preferred treatment option in hospitalized patients, together with DPP-4 inhibitors and GLP-1 RA |
Korytowski [16] June 2020 | Discontinue in hospitalized patients, due to the possibility of sudden and rapid deterioration in clinical status | Discontinue in hospitalized patients | Discontinue in patients hospitalized with acute disease | Generally not recommended in patients with acute disease, due to potential for abrupt deteriorations in clinical status; avoid saxagliptin and alogliptin due to higher risk for HF | Preferred treatment option in hospitalized patients |
Koliaki [17] July 2020 | Discontinue in patients who are hospitalized with severe disease and who have hypoxia and haemodynamic instability, due to the risk of lactic acidosis; monitor renal function | Continue in non-hospitalized patients with mild disease, due to significant cardiorenal protective effects; discontinue in patients who are hospitalized with severe disease, due to the risk of euglycemic DKA in the event of dehydration and insulinopaenia | Continue with caution in non-hospitalized patients with mild disease; discontinue in hospitalized patients with severe disease; consider dehydration risk due to GI adverse events; ensure adequate fluid and food intake | Continue in non-hospitalized patients with mild disease, due to favourable safety profile and suitability for a wide range of renal function | Should be continued; monitor serum potassium levels to prevent hypokalaemia |
Futatsugi [20] October 2020 | Continue in asymptomatic or mild Covid-19; should generally be discontinued in hospitalized patients | Consider discontinuing in patients at high risk of respiratory failure and thrombosis | As a precaution, discontinue in hospitalized patients due to possible GI adverse events that may worsen dehydration | Relatively safe to continue in mild-to-moderate Covid-19, but consider switching to insulin in severe disease | Preferred treatment option in hospitalized patients |
Lim [15] November 2020 | Not encouraged for use in critically ill patients, but can be used with caution; recommended in all other settings | Not recommended for moderate-to-severe (i.e. hospitalized) Covid-19, due to the potential for osmotic diuresis and possibly dehydration, which may be risk factors for AKI and DKA; can be used with caution in patients who are not hospitalized | Can be used with caution in critically ill patients; recommended in all other settings, especially due to cardiorenal benefits | Can be used in most patients, across a broad spectrum of Covid-19 severity, as generally well tolerated | Insulin is mainly recommended for critically ill patients with severe disease (as an infusion), but can be used in all patients |
Sun [14] January 2021 | Continue in mild-to-moderate Covid-19; avoid in critically ill patients | Continue in mild-to-moderate Covid-19; avoid in critically ill patients | Continue in mild-to-moderate Covid-19; more data needed to know whether suitable for acutely ill patients | Continue in mild-to-moderate Covid-19; more data needed to know whether suitable for acutely ill patients | Preferred treatment option for critically ill patients |