Managing diabetes during the COVID-19 pandemic

April 8, 2020

Jamie Hartmann-Boyce, Elizabeth Morris, Clare Goyder, Jade Kinton, James Perring, David Nunan, Kamlesh Khunti

On behalf of the Oxford COVID-19 Evidence Service Team
Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences,
University of Oxford (JHB; DN)
Nuffield Department of Primary Care Health Sciences,
University of Oxford (EM; CG)
Medical Sciences Division, University of Oxford (JP; JK)
University of Leicester, UK (KK)

Correspondence to jamie.hartmann-boyce@phc.ox.ac.uk


VERDICT
Alongside general COVID-19 guidance to reduce risk, people with diabetes (PWD) have been advised to aim for tighter glucose control where appropriate and feasible, though the evidence behind this recommendation has not been identified. Routine care of diabetes will be significantly disrupted during the current pandemic. Stress levels and disruptions to diet and physical activity may also contribute to worsening outcomes during and following the pandemic. Interventions to improve self-management of or self-education for diabetes may be limited in their generalisability, but text-message interventions and self-monitoring of blood glucose are the most promising strategies.

BACKGROUND
People with diabetes (PWD) are at increased risk of serious illness from COVID-19. Understanding this risk and the best ways to mitigate it is key to enabling patients, carers, and healthcare professionals to make informed choices about ways to manage PWD during the COVID-19 pandemic. A companion review evaluates evidence about the risks of COVID-19 in people with diabetes. This review addresses the below questions:

  • How can PWD reduce risk from COVID-19?
  • What is the evidence on health anxiety and diabetes-related distress during the COVID-19 pandemic?
  • How can PWD best self-manage their condition in the context of the COVID-19 pandemic?
  • How can routine care of PWD be managed given the disruption in healthcare and other services?
  • What is the evidence on the management of PWD presenting with COVID-19?

CURRENT EVIDENCE

Reducing the risk of COVID-19 in PWD

PWD are advised to follow general guidance on risk reduction, including social distancing and hand washing. There is little advice specific to PWD. A narrative review (not systematic) emphasises the importance of good glycaemic control during the COVID-19 pandemic as it may help in reducing the risk of infection and severity. The authors recommend:

  • More frequent blood glucose monitoring (in people who self-monitor),
  • to take influenza and pneumonia vaccinations as offered,
  • PWD with coexisting heart or kidney disease require special care to stabilise their cardiac/renal status.

Health anxiety and diabetes-related distress during the COVID-19 pandemic

In addition to overarching concerns about the impact of social isolation on mental health and wellbeing during the COVID-19 pandemic, Diabetes UK notes that PWD may be feeling particularly worried or anxious during this time. PWD are more prone to mental health issues than the general population, including anxiety and depression. There is no evidence directly about the management of diabetes-related anxiety or distress during the COVID-19 pandemic. A feature article for diabetes management during humanitarian crises notes the importance of psychological barriers and highlights women with diabetes are at particular risk of de-prioritising self-care and health care because they are often relied on as primary caregivers during crises. Adherence can worsen when people are distressed or have depression and can worsen during and after disasters.

In the general literature, there is mixed evidence on interventions to reduce diabetes-related distress. A Cochrane review of 30 randomized controlled trials (n = 9,177) found no effect of psychological interventions on diabetes-related distress or health-related quality of life. In contrast, five other reviews found small improvements but judged the certainty of the evidence to be very limited due to issues with study quality and/or heterogeneity. The reviews include people with type 2 diabetes; people with type 2 diabetes and an additional risk factor contributing to vulnerability; both type 1 and type 2; majority type 2; mindfulness-based interventions).

The vast majority of the interventions tested across all reviews involved face-to-face contact which is unlikely to be feasible in the current context. Web-based interventions may be possible, but a systematic review of 16 randomized controlled trials of web-based psychological interventions in improving wellbeing in PWD found no significant differences in depression or distress when meta-analysing nine studies.

Self-education/management of diabetes in the context of the COVID-19 pandemic

Due to the emerging nature of the pandemic, there is little information on what self-management or self-education tools are effective in the specific context of COVID-19. Diabetes UK guidance suggests that PWD follow their “current routine” including checking feet daily, keeping to a healthy diet, and keeping active. They also warn against stockpiling medication and supplies, and note that insulin pump warranties due to expire soon will be extended or a replacement provided by the company if needed at any point.

A commentary on management of diabetes in China during the COVID-19 outbreak notes (but does not reference) that a variety of online services were implemented for PWD with the aim of preventing person-to-person transmission, including educational videos and e-books on diabetes self-management provided for the public via a WeChat mobile app. The authors state, “these online services and resources have played remarkable roles” but do not provide data or references to back up this assertion. The wider literature on care of long-term conditions during national emergencies suggests a role for educational materials and remote consultations. More detail can be found in a separate rapid review.

Evidence for non resource-intensive interventions to optimise self-management not requiring face-to-face contact.

The interventions generally fall into four categories: text-message; mobile phone app; web or computer-based; self-monitoring of blood glucose.

The evidence on text-message based interventions shows the most promise of the modalities reviewed. This includes both automated interventions and those with input from healthcare professionals. A systematic review of 13 randomized controlled trials (n= 1164, type 1 and type 2) showed a significant reduction in HbA1c in people allocated to text-message based interventions for improving glycaemic control compared to control (mean difference -0.62%, 95% CI -0.82 to -0.41). Subgroup analysis found significant HbA1c reduction in both type 1 and type 2 diabetes. A second systematic review and meta-analysis of personalised text-messaging interventions for improving T2DM self-management found a “substantial and significant effect” on HbA1c (weighted mean effect size Hedge’s g = 0.54, 95% CI = 0.08–0.99, 11 studies, n = 949). In contrast, a Cochrane review assessing mobile phone messaging designed to facilitate self-management of long-term illnesses found moderate-quality evidence from 2 studies that there was no difference between text-messaging interventions compared with usual care or email reminders for HbA1c or diabetes complications, but did find moderate-quality evidence of improvement of capacity to self-manage diabetes ((Self‐Efficacy for Diabetes score (MD 6.10, 95% CI 0.45 to 11.75), Diabetes Social Support Interview pooled score (MD 4.39, 95% CI 2.85 to 5.92)).

Evidence on smartphone based applications is limited and mixed. A 2019 systematic review and meta-analysis of the effectiveness of smartphone-based self-management interventions for type 2 diabetes found 22 RCTs (n = 2645).  Interventions comprised education, reminders, monitoring and/or feedback, and were compared to usual care or no smartphone intervention. When results were pooled, the intervention resulted in significantly improved self-efficacy (but with high levels of statistical heterogeneity), self-care activities, health-related quality of life, and HbA1c. Other reviews have been less promising. A systematic review to evaluate the utility and effectiveness of mobile and web-based health apps to support self-management in young people with chronic illnesses found two studies looking at T1DM, neither of which demonstrated any effect. A systematic review of free apps in Spanish for diabetes management (2019; did not evaluate effectiveness) found that most apps lacked quality certifications and very few provided scientific references. The top-scored apps were mainly those linked to technologies and included: OneTouch Reveal™, Social Diabetes™, mySugr: App Diario de diabetes™, Diabetes menú™, Tactio SALUD™ and Diabetes:M™.”

Evidence on web- and computer-based interventions for improving diabetes self-management is also limited and mixed.

A Cochrane review assessing the effects of computer‐based self‐management interventions for T2DM found 16 RCTs with 3578 participants. There was no evidence for improving depression or health-related quality of life, but small benefits were observed for HbA1c (mean difference ‐0.2% (95% confidence interval (CI) ‐0.4 to ‐0.1; 11 trials, n = 2637) which are unlikely to be clinically meaningful. A systematic review of the effectiveness of mobile applications for improving glycaemic control in T1DM found mixed effects with 3 of the 9 studies of stand-alone apps finding significant improvement in HbA1c and glucose monitoring, and concluded that the development and evaluation of more comprehensive applications for use in diabetes are warranted.

The evidence for increased frequency of blood glucose monitoring in type 2 diabetes generally shows effects in the short term (up to 6 months), though at 12 months is less certain. Arguably short-term effects are most relevant in the current pandemic context.

A systematic review of randomized controlled trials to evaluate the impact of the frequency of blood glucose monitoring in people with T2DM found that self-monitoring blood glucose 8 to 14 times a week was associated with better HbA1c control at six and 12 months (at six months, MD −0.46%, 95% CI −0.54 to −0.39 3 studies, n = 806) with moderate levels of unexplained statistical heterogeneity (I squared = 67%). In a Cochrane review of self-monitoring of blood glucose in T2DM in people not using insulin compared to usual care and/or monitoring of urine glucose (12 RCTs, n = 3259), a meta-analysis of 9 studies showed a small improvement in HbA1c at up to 6 months follow-up (‐0.3%; 95% confidence interval (CI) ‐0.4 to ‐0.1; 2324 participants); but the effect was less certain at 12 months. A 2019 systematic review of technology-based interventions for children and young people with diabetes narratively reported that “the most positive findings were associated with technology-based health interventions targeting self-monitoring of blood glucose”.

In addition to issues with study quality and unexplained heterogeneity, the evidence for remotely delivered self-management interventions is limited in three key regards as it relates to the question posed above. The first issue is generalisability to the current pandemic context; some of the remote interventions tested may not be widely available, or may require healthcare resources to be set up which may be limited at the present time. Secondly, interventions supporting increased frequency of blood glucose monitoring require PWD to have access to monitoring technology (and training to use this) that is not widely available to many people with type 2 diabetes (for example, as part of routine care in the UK). Thirdly, though most reviews report data on intervention modality, intervention content (e.g. the behaviour change techniques used in the interventions) are not discussed in detail. It may be that the content of the interventions rather than their modality has a greater impact on effectiveness, but without comparative data we are unable to draw conclusions about what content is most promising.

Finally, it is worth considering that diet and physical activity are mainstays of diabetes self-management. Disruption to food supply is a threat to diabetes management during national emergencies. A feature article summarising challenges and recommendations for diabetes management during humanitarian crises, with focus on the Syrian crisis as a case study, highlights dietary quality and a reliance on high-carbohydrate foods as key issues for diabetes management during crises, and also notes that physical activity will be reduced. Within the context of the current pandemic, where disruptions in food supply are an issue in many countries due to stockpiling and transportation issues, there is very little discussion of this potential challenge to diabetes management in the literature.

A narrative review (not systematic) of clinical considerations for PWD during the COVID-19 pandemic notes that “Attention to nutrition and adequate protein intake is important. Any deficiencies of minerals and vitamins need to be taken care of,” and also notes that, “Exercise has been shown to improve immunity, though it might be prudent to be careful and avoid crowded places like gymnasia or swimming pools.” A recent feature article notes food supply issues for PWD in the UK, including the need for specific foods to treat low blood sugars, and describing cases where PWD are struggling to get the food they need or are restricted in how much they can buy, resulting in high levels of anxiety.

Routine diabetes care in the context of the current pandemic 

National emergencies, including pandemics, disrupt care of long-term conditions (LTCs). General strategies for mitigation of the risks and harms of this disruption are covered in a separate review. Considerations as they relate specifically to diabetes management are covered here. Despite recent guidelines (summarised below), a commentary has noted the lack of clarity for PWD at the current time, including uncertainties around when it is appropriate to call a paramedic, what to do if emergency services are overwhelmed, and whether hospital appointments are taking place. Diabetes UK has advised PWD to access medical assistance remotely wherever possible, and to speak to healthcare professionals to consider whether appointments can be postponed. They note that regular check-ups, including annual diabetes reviews, eye screening, and routine foot checks, will not be available but that PWD “should be able to reschedule when things go back to normal.”

The Royal College of Physicians, Association of British Clinical Diabetologists, and NHS have issued a clinical guide for the management of people with diabetes during the COVID-19 pandemic. The guide outlines considerations for “the best local solutions to continue the proper management of people with diabetes while protecting resources for the response to coronavirus.” They note that currently 18% of hospital beds are occupied by someone with diabetes and that as PWD are more likely to have severe manifestations of COVID-19, the percentage is likely to increase, so inpatient diabetes services will need to continue and potentially increase capacity. In secondary care, they note that multidisciplinary team (MDT) foot services and pregnancy services may need to continue at full capacity with consideration of moving support to remote forms where possible. For primary care, the recommendation is to consider routine diabetes care delivered virtually in the context of broader LTC management and prioritisation, taking into account individual risk factors and clinical needs.

NHS London Clinical Networks has developed an algorithm for outpatient prioritisation for specialist diabetes departments during the pandemic. The algorithm indicates that urgent face-to-face appointments should continue in the following circumstances: a new diagnosis of T1DM; urgent insulin start where symptomatic, HbA1c > 10%, or ketones detected; teaching blood glucose monitoring for urgent reasons (e.g. pregnancy); urgent blood test monitoring (e.g. declining renal function, raised potassium, low sodium); or in cases where physical examination is essential (e.g. foot ulcer, infection, some points in pregnancy). Virtual (telephone, video or email) consultations are recommended for: follow-up of new T1 diagnoses; vulnerable patients (recent hospital admission, recurrent severe hypoglycaemia, HbA1c > 11%); intensive follow-up in high-risk situations (e.g. pregnancy); or where the risk of attending an appointment face-to-face is greater than the benefits. They recommend the following be deferred: routine appointments where diabetes is stable and well-managed; face-to-face structured group education courses; flash glucose monitoring start sessions; where the risk of attending an appointment is greater than the benefits; and where deferring appointments will not compromise clinical care.

Some specific guidance is available regarding the management of diabetic foot clinics during the pandemic. Guidance from NHS England suggests that access to outpatient and inpatient MDT foot services are essential, that access continues for those with acute or limb threatening problems, and that all new referrals should ideally be reviewed within 24 hours. It then outlines a number of risks to these services and suggests the following for mitigation: MDTs to review service arrangements; workforce capacity assessment to be undertaken; collaboration with other providers; and possible changes to clinic locations. A preprint commentary has proposed a structure for a Pandemic Diabetic Foot Triage system and warns against classifying diabetic foot ulcer procedures and surgeries as non-essential, as without appropriate care this could lead to an increase in amputations and deaths.

As evidenced from the above guidance, remote support is likely to be relied upon heavily for diabetes care during this period. As described elsewhere, studies of remote consultations have generally found positive results, though their generalisability to the current pandemic may be limited.  Within diabetes specifically, we found little evidence. A 2016 systematic review of interventions to improve compliance with therapies aiming to reduce HbA1c in type 1 diabetes found no effect on HbA1c in the six studies of telecare (mean difference -01.24%, 95% CI -0.268 to 0.020, n = 494). However, the comparator groups of half the included RCTs involved standard medical care such as quarterly face-to-face reviews with a nurse practitioner and/or endocrinologist.  Such access to in-person usual care may be reduced in the context of the current pandemic, limiting the generalisability of these results.

By contrast, an observational study to determine if mobile phone support for sick-day management is associated with reduced hospital admissions with diabetic ketoacidosis (DKA) for young adults with type 1 DM (n = 350) found that mobile phone support was associated with reduced progression of ketosis to DKA in young adults despite poor diabetes control.

A feature article summarising challenges and recommendations for diabetes management during humanitarian crises, with focus on the Syrian crisis as a case study, recommends the following goals:

Short-term (days to weeks)

  1. Prioritise insulin for patients with T1DM
  2. Ensure continuous access to essential diabetes medications
  3. Provide appropriate diabetes education for patients with a focus on hypoglycaemia and sick-day guidelines

Long terms (weeks to months)

  1. Provide access to quality diabetes care and medications
  2. Train local and international healthcare providers on diabetes care
  3. Develop clinical guidelines for diabetes management during crises

Management of PWD with COVID-19

Guidance specific to COVID-19 is covered here; general guidance for sick-day rules, medications, and hospitalisation not specific to COVID-19 are not covered. General sick day and medication guidance are available from Diabetes UK; Patient.info (for patients and professionals); NICE; TREND; and ISPAD, as well as other sources.

Medication management is a key issue for PWD when unwell. It is unclear if there are specific considerations related to COVID-19. A narrative review (not systematic) of clinical considerations for PWD during COVID-19 suggests: that anti-hyperglycemic agents that can cause volume depletion or hypoglycemia should be avoided; that dosage of oral anti-diabetic drugs may need to be reduced; that oral agents especially metformin and sodium glucose cotransporter-2 inhibitors (SGLT2i ) need to be stopped; and that insulin is the preferred agent for control of hyperglycemia in hospitalised sick patients. Diabetes UK also emphasises the need to discontinue SGLT2i when unwell (generic names include dapagliflozin, canagliflozin, empagliflozin; brand names Forxiga, Invokana, and Jardiance).

Many PWD are prescribed ACE inhibitors to prevent or control diabetes complications; it has been suggested that these have the potential to both benefit and cause harm in COVID-19. A recent rapid review provides an algorithm for patients taking ACE-1 inhibitors or an ARB; advice regarding use of ACE inhibitors during the COVID-19 pandemic is under ongoing review and may change as more data becomes available.

Management in the community has been covered by recent guidance and generally follows standard sick-day rules for PWD. Guidance from NHS England includes sick days rules specific to COVID-19 for type 1 (separate for pump and injection) and T2DM. These include instructions on prescriptions (recommended 1 month supply of all, plus backup supplies with an alternative means of insulin delivery if on an insulin pump, in case of pump failure), recommendations for insulin dosage and other medications (including discontinuation of some medications whilst unwell), instructions on increasing the frequency of blood glucose monitoring, and clear guidance on when to call 999. Diabetes UK also offers advice for PWD experiencing symptoms of COVID-19. Those specific to PWD include:

  • Following advice of diabetes care provider;
  • checking blood sugar more frequently for people who routinely check their blood sugars at home (every 4 hours including at night T1DM);
  • testing for ketones;
  • contacting healthcare provider if the blood sugar level is high or if ketones are present;
  • being aware of the signs of hyperglycemia for those who don’t routinely test at home and contacting a healthcare provider if experiencing symptoms;
  • staying hydrated;
  • trying to eat or have drinks with carbohydrates for energy;
  • getting medical help as soon as possible if vomiting or not able to keep fluids down.

A narrative review (not systematic) of clinical considerations for PWD during the COVID-19 pandemic advises that people with T1DM should “measure blood glucose and urinary ketones frequently if fever with hyperglycemia occurs. Frequent changes in dosage and correctional bolus may be required to maintain normoglycemia.”

Guidance is also available for hospitalised patients. NHS England has published specific guidance on management of diabetes in emergency departments during the coronavirus pandemic, which includes referring to local specialist diabetes teams and instructions on management of hyperglycaemia. The guidance also includes discharge packs (type 1 and type 2) for patients being discharged from hospital after admission for COVID-19. A document shared on social media with initial insights from London notes that: atypical ketosis was observed in type 2 diabetes; fluid replacement may need to be tempered during DKA management due to risk of ARDS; in a subset in a ventilated cohort high doses of insulin were required to manage hyperglycaemia; and as patients often need to be nursed prone, which interrupts feeding, there is paradoxically also a risk of hypoglycaemia. A recently published commentary on the management of PWD hospitalised for COVID-19  suggests a need for a tailored therapeutic strategy and optimal goal of glucose control formulated based on clinical classification, coexisting comorbidities, age and other risk factors. Post-discharge, they recommend blood glucose homeostasis be maintained continuously for 4 weeks and advise that patients need to avoid infectious diseases due to a lower immune response.

CONCLUSIONS

  • There is little evidence on how PWD can reduce their risk during the COVID-19 pandemic beyond following general infection control guidance. More frequent blood glucose monitoring (in people who self-monitor) and taking influenza and pneumonia vaccinations have been suggested, though it is unclear what evidence was used to make these recommendations.
  • We found no evidence on whether or how diabetes-related distress and anxiety may be heightened during the pandemic, nor evidence on how to manage this.
  • Interventions to improve self-management of or self-education for diabetes may be limited in their generalisability to the COVID-19 pandemic. Text-message interventions and self-monitoring of blood glucose are the most promising strategies based on the literature at hand.
  • Routine diabetes care will be significantly impacted during the pandemic. Guidelines are available for triaging care, which generally recommend some urgent face-to-face clinics continuing with routine check-ups and care of well-controlled diabetes be deferred, and other services provided by remote means where possible.
  • Management of PWD with COVID-19 generally follows standard sick-day rules. There may be specific considerations around ACE inhibitors, glucose control if hospitalised, and access to medical care and supplies.

End.

Disclaimer:  the article has not been peer-reviewed; it should not replace individual clinical judgement and the sources cited should be checked. The views expressed in this commentary represent the views of the authors and not necessarily those of the host institution, the NHS, the NIHR, or the Department of Health and Social Care. The views are not a substitute for professional medical advice.

AUTHORS 

Jamie Hartmann-Boyce is a departmental lecturer and deputy-director of the Evidence-Based Health Care DPhil programme within the Centre for Evidence-Based Medicine in the Nuffield Department of Primary Care Health Sciences, University of Oxford. She has type 1 diabetes. @jhb19

 

Elizabeth Morris is a General Practitioner, and Wellcome Trust Doctoral Research Fellow at the Nuffield Department of Primary Care Health Sciences, University of Oxford.  Her research focuses on interventions to support people with type 2 diabetes. @Lmo_Ox

 

Clare Goyder is a General Practitioner in Oxford and a Wellcome Trust Doctoral Fellow at the Nuffield Department of Primary Care Health Sciences, University of Oxford.

 

 

James Perring is a 5th-year medical student at St. Catherine’s College, Oxford.

 

 

 

Jade Kinton is a 4th year medical student at Exeter College, Oxford.

 

 

 

David Nunan is a Senior Research Fellow at the Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford. He is also an Editor at the BMJ Evidence-Based Medicine journal and Director of PG Certificate in Teaching Evidence-Based Health Care; @dnunan79

Kamlesh Khunti is Professor of Primary Care Diabetes & Vascular Medicine University of Leicester, UK and is a General Practitioner.

 

 

 

 

SEARCH TERMS
Searches for this review and a companion review were run by Nia Roberts, subject librarian, between the 25 and 31st March, using the following terms.

(coronavirus*[Title] OR coronovirus*[Title] OR coronoravirus*[Title] OR coronaravirus*[Title] OR corono-virus*[Title] OR corona-virus*[Title] OR “Coronavirus”[Mesh] OR “Coronavirus Infections”[Mesh] OR “Wuhan coronavirus” [Supplementary Concept] OR “Severe Acute Respiratory Syndrome Coronavirus 2″[Supplementary Concept] OR COVID-19[All Fields] OR CORVID-19[All Fields] OR “2019nCoV”[All Fields] OR “2019-nCoV”[All Fields] OR WN-CoV[All Fields] OR nCoV[All Fields] OR “SARS-CoV-2”[All Fields] OR HCoV-19[All Fields] OR “novel coronavirus”[All Fields]) AND ((diabetes mellitus[MeSH Terms]) OR (diabet* OR “metabolic disease”)) Filters: Systematic ReviewsPubmed5
(coronavirus*[Title] OR coronovirus*[Title] OR coronoravirus*[Title] OR coronaravirus*[Title] OR corono-virus*[Title] OR corona-virus*[Title] OR “Coronavirus”[Mesh] OR “Coronavirus Infections”[Mesh] OR “Wuhan coronavirus” [Supplementary Concept] OR “Severe Acute Respiratory Syndrome Coronavirus 2″[Supplementary Concept] OR COVID-19[All Fields] OR CORVID-19[All Fields] OR “2019nCoV”[All Fields] OR “2019-nCoV”[All Fields] OR WN-CoV[All Fields] OR nCoV[All Fields] OR “SARS-CoV-2”[All Fields] OR HCoV-19[All Fields] OR “novel coronavirus”[All Fields]) AND ((diabetes mellitus[MeSH Terms]) OR (diabet* OR “metabolic disease”))Pubmed36
(coronavirus OR COVID-19) AND diabetesTRIP36
(coronavirus OR COVID-19) AND diabetesGoogle
(coronavirus OR COVID-19) AND diabetesGoogle Scholar
(coronavirus*[Title] OR coronovirus*[Title] OR coronoravirus*[Title] OR coronaravirus*[Title] OR corono-virus*[Title] OR corona-virus*[Title] OR “Coronavirus”[Mesh] OR “Coronavirus Infections”[Mesh] OR “Wuhan coronavirus” [Supplementary Concept] OR “Severe Acute Respiratory Syndrome Coronavirus 2″[Supplementary Concept] OR COVID-19[All Fields] OR CORVID-19[All Fields] OR “2019nCoV”[All Fields] OR “2019-nCoV”[All Fields] OR WN-CoV[All Fields] OR nCoV[All Fields] OR “SARS-CoV-2”[All Fields] OR HCoV-19[All Fields] OR “novel coronavirus”[All Fields]) AND (((((“Diabetes Mellitus, Type 1″[Mesh]) OR “Diabetes Complications”[Mesh]) OR (“Diabetes Mellitus”[Mesh] (AND “Comorbidity”[Mesh] OR”Hypertension”[Mesh]))) OR (“Insulin”[Mesh] OR “Hypoglycemic Agents”[Mesh])) OR ((“type 1 diabetes”[Title/Abstract] OR “type i diabetes”[Title/Abstract] OR insulin[Title/Abstract]) OR (diabet*[Title/Abstract] AND (complications[Title/Abstract] OR retinopathy[Title/Abstract] OR nephropathy)[Title/Abstract])))PubMed30
diabetesLitCOVID29
Search: (influenza OR pneumonia OR SARS OR MERS OR severe respiratory infections OR acute respiratory infections OR “Respiratory Tract Infections”[Mesh]) AND (((((“Diabetes Mellitus, Type 1″[Mesh]) OR “Diabetes Complications”[Mesh]) OR (“Diabetes Mellitus”[Mesh] (AND “Comorbidity”[Mesh] OR”Hypertension”[Mesh]))) OR (“Insulin”[Mesh] OR “Hypoglycemic Agents”[Mesh])) OR ((“type 1 diabetes”[Title/Abstract] OR “type i diabetes”[Title/Abstract] OR insulin[Title/Abstract]) OR (diabet*[Title/Abstract] AND (complications[Title/Abstract] OR retinopathy[Title/Abstract] OR nephropathy)[Title/Abstract]))) Filters: Systematic Reviews, from 2005 – 2020PubMed30
(diabetes OR diabetic AND (systematicreviews[Filter])) AND (influenza OR pneumonia OR SARS OR MERS OR severe respiratory infections OR acute respiratory infections OR “Respiratory Tract Infections”[Mesh])PubMed56
(coronavirus OR COVID-19) AND (“type 1 diabetes” OR “type i diabetes” OR insulin OR “diabetic neuropathy” OR “diabetic retinopathy”)Google
(coronavirus OR COVID-19) AND (“type 1 diabetes” OR “type i diabetes” OR insulin OR “diabetic neuropathy” OR “diabetic retinopathy”)Google Scholar
(coronavirus OR COVID-19) AND diabetes AND (“social distancing” OR “social Isolation” OR shielding OR hadwashing OR handwashing OR “infection control” OR masks OR masking)Google
(coronavirus OR COVID-19) AND diabetes AND (“social distancing” OR “social Isolation” OR shielding OR hadwashing OR handwashing OR “infection control” OR masks OR masking)Google Scholar
((influenza OR pneumonia OR SARS OR MERS OR severe respiratory infections OR acute respiratory infections OR “Respiratory Tract Infections”[Mesh])) AND (((“social distance”[Title/Abstract] OR “social distancing”[Title/Abstract] OR “social isolation”[Title/Abstract] OR handwashin[Title/Abstract] OR hand-washing[Title/Abstract] OR “hand hygiene”[Title/Abstract] OR masks[Title/Abstract] OR masking[Title/Abstract]) OR (infection control[Title])) OR ((((“Hand Disinfection”[Mesh]) OR “Infection Control”[Mesh:NoExp]) OR “Patient Isolation”[Mesh]) OR “Masks”[Mesh])) AND diabetesPubMed22
Search: ((discontinu*[Title/Abstract] OR stop*[Title/Abstract]) AND (((“Metformin”[Mesh]) OR “Hypoglycemic Agents”[Mesh]) OR (metformin[Title/Abstract] OR gliflozin*[Title/Abstract] OR sglt2 inhibitor*[Title/Abstract] OR sglt-2 inhibitor*[Title/Abstract] OR sodium glucose transporter-2 inhibitor*[Title/Abstract] OR dipeptidyl peptidase inhibitor*[Title/Abstract] OR glucoside hydrolase inhibitor*[Title/Abstract] OR amylin receptor agonist*[Title/Abstract]))) AND (diabetes mellitus[MeSH Terms] OR diabet*[Title/Abstract]) Filters: Systematic ReviewsPubMed27
Search: ((discontinu*[Title] OR stop*[Title] OR persist*[Title] OR non-persist*[Title] OR complian*[Title] OR non-complian*[Title] OR adhere*[Title] OR non-adhere*[Title]) AND (((“Metformin”[Mesh]) OR “Hypoglycemic Agents”[Mesh]) OR (metformin[Title/Abstract] OR gliflozin*[Title/Abstract] OR sglt2 inhibitor*[Title/Abstract] OR sglt-2 inhibitor*[Title/Abstract] OR sodium glucose transporter-2 inhibitor*[Title/Abstract] OR dipeptidyl peptidase inhibitor*[Title/Abstract] OR glucoside hydrolase inhibitor*[Title/Abstract] OR amylin receptor agonist*[Title/Abstract]))) AND (diabetes mellitus[MeSH Terms] OR diabet*[Title/Abstract]) Filters: Systematic ReviewsPubMed22
((((“Metformin”[Mesh]) OR “Hypoglycemic Agents”[Mesh]) OR (metformin[Title/Abstract] OR gliflozin*[Title/Abstract] OR sglt2 inhibitor*[Title/Abstract] OR sglt-2 inhibitor*[Title/Abstract] OR sodium glucose transporter-2 inhibitor*[Title/Abstract] OR dipeptidyl peptidase inhibitor*[Title/Abstract] OR glucoside hydrolase inhibitor*[Title/Abstract] OR amylin receptor agonist*[Title/Abstract])) AND ((sick day rule* OR sick day advice* OR sick day manag* OR (“sick day” AND medication*) OR sick day[ti] OR sick days[ti]) AND (english[Filter])) AND ((english[Filter]) AND (2010:2020[pdat]))) OR ((sick day rule* OR sick day advice* OR sick day manag* OR (“sick day” AND medication*) OR sick day[ti] OR sick days[ti]) AND (diabetes mellitus[MeSH Terms] OR diabet*[Title/Abstract]) AND ((english[Filter]) AND (2010:2020[pdat])))PubMed53
“sick day rules” OR “sick daye management” OR “sick day advice”Google
intercurrent illness AND diabetesPubMed
intercurrent illness AND diabetesGoogle

REFERENCES
All references are available as hyperlinks from the text.