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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