Part 2: Stress, Kids and Supply Chain

in

We continue sharing expert responses to your top incoming questions.

Note these responses are not intended to be medical advice, for that—as always—you must consult your own personal physician. (View last week’s Top Ten.)

1. Does COVID-19 change your blood-sugar levels more than or differently than the flu?

This is this week’s top question, as so many people try to plan for how best to manage their type 1 diabetes (T1D) should they become ill with COVID-19. However, experts tell us there is not enough evidence to indicate one way or another. However, one doctor shared that she is seeing blood-sugar levels decrease in type 2 patients with the virus because they are not able to eat properly.

“Any illness can cause fluctuations in glucose levels. During illness, it’s important to monitor glucose and ketone levels more frequently and follow the sick day protocol provided by your diabetes care team. At this time, there is no data on the specific effect of COVID-19 on glucose levels that I am aware of,” said Anastasia Albanese-O’Neill, Ph.D., ARNP, CDE, a clinical assistant professor and director of diabetes education and clinic operations in the University of Florida, Department of Pediatrics.

“I don’t have any type 1 patients with COVID-19, but in our type 2 patients, because the illness causes (poor diet or inability to keep food down), blood sugars have gone down. Flu patients have increased blood sugars,” said Dr. Anne Peters, Director of the University of Southern California Clinical Diabetes Programs and practicing physician.

said Dr. Anne Peters, Director of the University of Southern California Clinical Diabetes Programs and practicing physician.

2. If children are less likely to show symptoms or just mild symptoms with COVID-19, should parents more closely monitor blood-glucose levels?

We are getting lots of questions from parents worried that their child may be ill with COVID-19, showing no real symptoms, but that the disease may cause blood-glucose fluctuations that they may not realize—prompting concerns about diabetic ketoacidosis (DKA).

First: Information from around the world supports the understanding that children are managing the novel coronavirus far better than adults, with the majority showing only mild signs of the illness.

Second: Doctors we spoke with said they have no indication what, if any, impact the virus may have in asymptomatic patients.

Doctors are advising that parents be watchful, but not to over-react and create unneeded anxiety in young people with T1D.

“During any illness, it’s important to follow the sick day protocol provided by your child’s doctor,” said Dr. Anastasia Albanese-O’Neill. “Check blood glucose frequently, monitor for ketones every 4 hours, keep your child hydrated and monitor for fever. Ketones are the first indication that a person with type 1 diabetes is at risk for DKA. If ketones are detected, or if your child is nauseous or vomiting, call your diabetes doctor for advice immediately.

Urine ketone test strips can be purchased over the counter or online without a prescription and are relatively inexpensive. Blood ketone test strips require a prescription.”

Third: Remember what to watch for with DKA.

Fourth: If you suspect DKA, do not hesitate to seek medical help. (See more below.)

3. Is it normal to feel scared? I am not sick, my family is well, but I am still on edge all the time.

Everyone manages situations of uncertainty differently. And this is a time of unprecedented uncertainty.

“It is easy to feel overwhelmed by all the news and with all changes we’ve had to make to our daily lives because of the current coronavirus pandemic [COVID-19]. When you throw diabetes into this mix, things can feel even more stressful,” said Mark Heyman, Ph.D., CDE, Vice President of Clinical Operations and Innovation at One Drop and Founder and Director of the Center for Diabetes and Mental Health (CDMH). See an interview Dr. Heyman gave to our colleagues at Beyond Type One.

“This situation is anything but normal, and it’s likely that you are feeling like things are out of your control. Let’s be honest—right now there are lots of things that you do not have control over and that is scary. Focusing on things you do have control over can give you a sense of stability, which can calm your mind.”

Nicole Johnson, DrPH, MPH, MA, said: “Stress can cause negative outcomes with our diabetes care. You need to take care of yourself, so you are able to take care of your diabetes and of the diabetes that exists in your family.”  Read and view tips from Dr. Johnson, Director of JDRF Research.

4. Is ibuprofen safe if I think I have COVID-19?

Despite some suggestions in the media that ibuprofen should be avoided with COVID-19, as of yet there is no evidence to suggest it is unsafe. Doctors we spoke with said they are not concerned about the use of ibuprofen, but urge anyone with doubts to first take acetaminophen (see caveats below).

The debate began in France, when their Health Minister linked ibuprofen to more serious complications with COVID-19 patients. The World Health Organization initially advised against the use of ibuprofen to counter flu symptoms, but then immediately reversed themselves saying they are not “aware of reports of any negative effects.”

  • For anyone that takes ibuprofen for other conditions (such as arthritis), there is no need to stop at this time.
  • Patients with advanced kidney damage should be cautious about using ibuprofen in general and this caution also applies to the current situation.
  • Some CGM sensors (including Dexcom G4 and G5, Medtronic Enlite and possibly others) are affected by acetaminophen and cause the sensor to show a higher reading than the true blood-glucose level over the 3-4 hours after taking a typical dose. Thus, if you use one of these sensors and suspect you may have COVID-19, experts recommend using a back-up glucose monitoring method (fingersticks) if taking acetaminophen.

5. Should I keep my regular doctor’s appointments?

Yes, but do it remotely. It is important to stay in contact with your physician—especially your endocrinologist—even during such extraordinary times when you may be in lockdown with restricted mobility. Most doctors have set up “virtual visits” through video conferencing and phone calls. Read our posting on how “telehealth / telemedicine” works and see a video with key advice.

“If possible, no one should go to a doctor’s office now. But the vast majority of our visits can be done through telemedicine,” Dr. Peters said. “I want to stay connected with my patients, so that I can keep them on a regular schedule and intervene if needed.”

If you are not feeling well, your doctor needs to know, as managing T1D through any illness is critically important. During an illness, your diet, ability to eat and physical stress all fluctuate, and can lead to elevated ketone levels, which may lead to diabetic ketoacidosis (DKA).

“The need to stay connected is ever more important,” Dr. Peters said.

Two other considerations: your insurance provider may require regular physician updates for prescription renewals; and you may face rescheduling issues if you miss an appointment, especially now as doctors are carrying heavier case loads due to the pandemic.

6. If I feel ill, should I get tested?

Earlier in the pandemic, experts urged testing to help identify potential contamination points and the need to self-isolate. Today, the CDC is saying “not everyone needs to be tested” as most areas are already in a state of self-isolation and evidence shows that most people experience only mild symptoms.

If you have T1D and suspect you may have COVID-19, you should contact and stay in touch with your physician/endocrinologist.

“If you are over 60, or over 60 with type 1 diabetes, you absolutely should call your doctor,” Dr. Peters said.

In most cases, doctors and the CDC are advising that people will have a mild illness and can recover at home without medical care.

  • As much as possible, stay away from others in your home. If possible, stay in a specific “sick room” and use a separate bathroom.
  • Cover your mouth and nose with a tissue when you cough or sneeze. Throw used tissues in a lined trash can, and wash your hands.
  • Do not share dishes, drinking glasses, cups, eating utensils, towels or bedding with other people in your home.
  • Routinely clean high-touch surfaces in your “sick room” and bathroom.

7. What are the warning signs that my case may need medical attention?

If you have T1D, you have two critical watch outs.

  1. According to the CDC, anyone with or suspects they may have COVID-19 should call their doctor if they have:
  • Trouble breathing
  • Persistent pain or pressure in the chest
  • New confusion or inability to arouse
  • Bluish lips or face
  1. T1D medical experts urge anyone who thinks they have COVID-19 or any illness to monitor their blood-glucose levels even more closely as well as their ketone levels and seek help if you show signs of diabetic ketoacidosis (DKA).

Dr. Peters advises that you first contact your personal doctor, so they may alert emergency room staff if needed. If you cannot reach your doctor, you should contact the ER prior to arrival.

“Tell them, clearly, that you have T1D and have elevated ketones and may have DKA. It is very, very important, as they have so many people coming in, for you to have a clear message.”

8. If I have to go to the hospital, what should I expect?

Images of doctors and hospital staff working in hazmat suits have created concern about seeking help. “Is the scary experience worth it?” we asked Dr. Anne Peters, who is working on the front lines of the disease in Los Angeles.

“Know that underneath what may look really scary, are people who want to hug you. Health care workers are heroes. Everyone’s goal is not to get sick. But if you do, they are here to help.”

If you have done everything you can at home and you still need help, you should seek help.

“A dehydrated child is a very, very serious problem.”

  • Call the hospital ahead of your arrival with a clear message on why you are coming in.
  • Have the youngest and healthiest parent take the child to the hospital. Do not take other children with you.
  • Wipe down the waiting room chair. Take a mask if available.
  • Keep the child from moving around, coming in contact with anything or anyone else.

9. If there are no supply chain issues, why is my pharmacy telling me they can’t refill my insulin right now?

We are getting this question a good deal, but have heard no indication that delays are for more than a few days, at most. To be clear, the issue is not with the supply chain as leading manufacturers of insulin and T1D supplies continue to assure the public that COVID-19 is not having an impact on their current manufacturing and distribution capabilities.

But, as orders are increasing—with individuals seeking more than their typical 30-day refills—some suppliers (pharmacies) are telling T1D customers that immediate refills are now going to take a few days.

A representative from Eli Lilly—one of the world’s top three insulin manufacturers—said the delay is “simply” getting the (insulin) from the warehouse to the pharmacy. “We are confident that we will have Lilly insulin manufactured and available to your pharmacy at whatever schedule you decided to pick it up. We’re here, we’re confident and we’re making your insulin 24 hours a day,” said Wade Neucks, director of Eli Lilly’s Patient Affordability Solutions. Access his full interview, conducted by our colleagues at Beyond Type One.

Link here to see what major manufacturers are saying, learn how to get home delivery and get help with insulin prescription costs.

10. What are my options if I lose my medical coverage?

 These are challenging days, and we hope that everyone in the T1D community remains healthy and safe. Economic changes and challenges are impacting so many of us, and it is good to be prepared. Toward that end, we share resources created by our JDRF team as well as those created by our colleagues at Beyond Type One.

Good luck. And take care.

By Lisa Popyk