Prioritize COVID-19 Vaccination in Both Types of Diabetes, Say Docs

The risk for increased COVID-19 severity in people with type 1 diabetes appears similar to that of type 2 diabetes, contrary to some official advice from the Centers for Disease Control and Prevention (CDC). The new finding indicates that people with both types should be priority for receiving a vaccine, investigators say.

The study is the first to prospectively evaluate both inpatients and outpatients and to examine COVID-19 severity factors in addition to death in people with type 1 and type 2 diabetes separately, and was published online December 2 in Diabetes Care.

Among the patients, who were seen at Vanderbilt University Medical Center in Nashville between March and August 2020, those with both type 1 and type 2 diabetes had between a three- and fourfold greater risk for COVID-19 hospitalization and greater illness severity than people without diabetes after adjustments for age, race, and a number of other risk factors.

This finding is important since as of December 1, 2020, the CDC has classified the diabetes types differently in terms of underlying medical conditions that increase the risk for severe COVID-19.

Adults of any age with type 2 diabetes are considered "at increased risk of severe illness" from the virus that causes COVID-19 whereas CDC says those with type 1 "might be at an increased risk."

Lead author of the new paper Justin M. Gregory, MD, told Medscape Medical News: "I think this needs revision based on the current evidence. I think the data presented in our study and that of Barron et al in Lancet Endocrinology 2020 indicate the need to place type 1 diabetes at parity with type 2 diabetes."

"These studies indicate both conditions carry an adjusted odds ratio of three to four when compared with people without diabetes for hospitalization, illness severity, and mortality," he stressed.

Vaccines Look Promising for Patients With Diabetes

There were no phase 3 vaccine data available for the vaccine at the time that Gregory, of the Ian M. Burr Division of Pediatric Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, and colleagues were writing their manuscript in late summer, so the article does not mention this.

But now, Gregory says, "Based on the initial press releases from Pfizer and Moderna, I am now optimistic that these vaccines might mitigate the excess morbidity and mortality from COVID-19 experienced by patients with diabetes."

"I am eager to see what we learn on December 10 and 17 [the scheduled dates for the meetings of the US Food and Drug Administration's Vaccines and Related Biological Products Advisory Committee to review the Pfizer and Moderna vaccines, respectively]."

But with the winter pandemic surge in the meantime, "Our investigation suggests that as COVID-19 hospitalizations rise, patients with both type 1 and 2 diabetes will comprise a disproportionally higher number of those admissions and, once hospitalized, demonstrate a greater degree of illness severity," he and his colleagues say.

"In light of these data, we call on our colleagues to emphasize the importance of social distancing measures and hand hygiene, with particular emphasis on patients with diabetes, including those in the most vulnerable communities whom our study affirms will face the most severe impact."

After Adjustments, Excess Severity Risk Similar for Both Diabetes Types

The new study data came from electronic health records at Vanderbilt University Medical Center, comprising 137 primary care, urgent care, and hospital facilities where patients were tested for SARS-CoV-2 regardless of the reason for their visit.

Between March 17 and August 7, 2020, a total of 6451 tested positive for COVID-19. Of those, 273 had type 2 diabetes and 40 had type 1 diabetes.

Children younger than 18 years accounted for 20.0% of those with type 1 diabetes and 9.4% of those without diabetes, but none of the type 2 group. The group with type 2 diabetes was considerably older than the type 1 diabetes and no-diabetes groups, 58 years versus 37 and 33 years, respectively.

Before adjustment for baseline characteristics that differed between groups, patients with type 1 diabetes appeared to have a risk for hospitalization and greater illness severity that was intermediate between the group with no diabetes and the group with type 2 diabetes, the researchers say.

But after adjustment for age, race, sex, hypertension, smoking, and body mass index, people with type 1 diabetes had odds ratios of 3.90 for hospitalization and 3.35 for greater illness severity, which was similar to risk in type 2 diabetes (3.36 and 3.42, respectively), compared to those without diabetes.

Deep Dive Explores COVID-19 Severity Risk Factors in Type 1 Diabetes

The investigators then conducted a detailed chart review for 37 of the 40 patients with type 1 diabetes and phone surveys with 15 of them.

The majority (28) had not been hospitalized, and only one was hospitalized for diabetic ketoacidosis (DKA) within 14 days of positive SARS-CoV-2 testing.

This contrasts with a report from the T1D Exchange, in which nearly half of 33 patients with type 1 diabetes and COVID-19 had been hospitalized with DKA. The reason for the discrepancy may be that more severe patients would more likely be referred to the T1D Exchange Registry, Gregory and colleagues hypothesize.

Clinical factors associated with COVID-19 severity (P < .05) in their study included a prior hypertension diagnosis, higher A1c, at least one prior DKA admission in the past year, and not using a continuous glucose monitor (CGM).

Hospitalizations were twice as likely and illness severity nearly twice as great among those with type 1 diabetes who were Black versus White. Just 8% of those with private insurance were hospitalized, compared with 60% of those with public insurance and 67% with no insurance (P = .001).

"Whereas previous reports have indicated proportionally higher rates of hospitalizations from COVID-19 among Black patients and those with public insurance, this study is the first to show a similar finding in the population with type 1 diabetes," Gregory and colleagues write.

Only 9% of patients using a CGM were hospitalized versus 47% who used blood glucose meters (P < .016). Similarly, hospitalizations occurred in 6% using an insulin pump versus 33% using multiple daily injections (P < .085).

But they note, "Our analysis cannot exclude the possibility that greater amounts of diabetes technology use are a surrogate for higher socioeconomic status."

This research was supported by the National Institute of Diabetes and Digestive and Kidney Diseases, JDRF, and the Appleby Foundation. The authors have reported no relevant financial relationships.

Diabetes Care. Published online December 2, 2020. Abstract

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