Dr. Richard Bernstein has a very clear message for people with diabetes: avoid coronavirus as much as possible and for as long as possible. The danger to people with diabetes – both from coronavirus itself and from the resultant stress placed on the healthcare system – is real.
“It’s much better to avoid getting infected than attempting to treat the infection, and to do that you need total isolation.”
Many of our readers will already be familiar with Dr. Bernstein. It’s very likely that no one person has ever known more about diabetes, and certainly nobody has ever understood its proper management more vitally.
This week Dr. Bernstein spoke about diabetes and the risks of COVID-19, the novel coronavirus, in the latest installment of his Youtube question & answer series.
Noting the extreme speed with which the pandemic has developed – “what I’m telling you today could well be outdated within a week” – Dr. Bernstein went on to describe COVID-19 as a very serious peril for people with Types 1 & 2 diabetes.
“I think that we have to do the maximum to not get infected. And that means not only adhering to what the local authorities tell you to do, but anticipating the local authorities, staying away from other people, especially if you’re in a locality where there are cases of COVID-19 within 20 miles of your home. You shouldn’t go to stores. Don’t invite people to your homes, don’t visit other people. Even other family members in other homes, stay away from them.”
Dr. Bernstein himself has arranged for all of his grocery, drugs and other supplies to be delivered to his front door. He answers the doorbell wearing a mask and gloves, and signs receipts with his own pen. He even recommends spraying down packages with rubbing alcohol.
“That’s how careful you have to be.”
Does Diabetes Make You More Likely to Contract COVID-19?
“My guess is yes… but are there any real statistics on this? I don’t know.”
It seems that nobody is sure if diabetes makes one more prone to initial infection with the novel coronavirus, nor how age and diabetes type might affect the probabilities. Accordingly, Dr. Bernstein applied many caveats to his discussion of this topic.
“We do know from general experience that diabetics are more susceptible to infection. Historically, this has been bacterial infections.”
“What’s the story with viral infections? I haven’t seen any studies indicating diabetics getting more viral infections. They may be out there, but I haven’t stumbled upon them. I can understand why the immune system would be impaired by high blood sugars … I certainly would expect that if you have a high blood sugar, that that large amount of glucose in your blood will predispose you to infections. Now that’s my guess, it’s just a guess.”
Those with healthier blood glucose levels, both in the present moment and in the past months and years, likely stand a better chance of resisting the virus.
Does Diabetes Make COVID-19 More Dangerous?
We have known from the early days of the pandemic that people with “diabetes” are much more likely to develop severe health consequences from COVID-19, including death. There has been much speculation over whether or not people with Type 1 diabetes should be included among the higher risk group, and how younger people with either type might be affected. The CDC declined to speculate on this subject.
Dr. Bernstein made it clear that all people of diabetes should consider themselves among the higher risk population:
“Once you have a viral infection, almost inevitably, almost in every case, the blood sugars go up.”
Rising blood sugars are known to hinder your own body’s ability to fight off infections. People with Type 1 diabetes have an additional, major concern:
“If the blood sugars go up high enough, you could get severely dehydrated and go into diabetic ketoacidosis. So, you could end up getting killed by your diabetes because you’re infected by a virus and you didn’t take adequate measures to treat the viral infection.”
Even those who lack the other preexisting conditions that make COVID-19 infection more dangerous, such as hypertension or old age, would be well-advised to consider their immune systems impaired. Many people with diabetes have years of hyperglycemia in their past, and although some of that damage is reversible with good glucose control, not all is.
“I see that virtually 100% of longstanding diabetics that come to see me have autonomic neuropathy. The largest nerve in the body is injured by high blood sugars. And you could bet that a lot of other things are injured. Perhaps every tissue in your body is adversely affected by the glucose. And why shouldn’t the immune system be likewise impaired? That’s guessing, that’s all it is, but I think we can expect it.”
If You Get Sick
Not all of us are lucky enough to have the opportunity to practice total isolation – indeed, there are people with diabetes on the very front lines of the battle against the illness – and undoubtedly even some of the most careful will contract the illness before a vaccine is developed. Much of Dr. Bernstein’s talk therefore concentrated on what people with diabetes should do if they suspect that they’ve contracted COVID-19.
One clear message emerged: care for yourself at home as much as possible.
“Hospitalization, for a diabetic, is very dangerous. If you get a fever and don’t have trouble breathing, you might be safer staying at home.”
Why? Well, for starters, the emergency room is a great place to get infected with COVID-19 if it turns out that you don’t already have it. But even at the best of times, many doctors and nurses are painfully inexperienced at managing the blood glucose levels of a person with diabetes. And if these professionals are as tragically overburdened as predicted, they will be even less able to pay attention to this critical element of care.
And with hospitals banning visitors, it will be even more difficult than ever for parents or caretakers to help monitor and adjust the blood sugar levels of their wards.
“It’s a real dilemma and there are no magical solutions. You might have to be on your toes on how to handle one situation after another if you’re in a hospital.”
If you are in the hospital and are capable of managing your own glucose levels, you should do what you can to retain control. Dr. Bernstein suggests you make a deal with your caregivers:
“You guys treat my COVID, I’ll treat my diabetes.”
At what point should COVID-19 symptoms prompt a trip to the hospital?
“It’s not that easy to answer… if it were me, I’d go if I were having trouble breathing.”
This generally dovetails with CDC recommendations, which are to stay at home unless you feel “emergency warning signs.” Those signs include trouble breathing, persistent chest pain or pressure, lethargy and bluish lips or face.
At Home Care
If you view the hospital only as a last resort, then you need to be prepared to care for yourself at home. Self-care is more challenging for people with diabetes, and Dr. Bernstein’s sick day preparations, while familiar in most regards, are very aggressive.
In order to avoid sending patients to the hospital, he advises extreme preemptive measures against dehydration, which can rapidly spiral into DKA. For patients that can afford it, he’ll prescribe a stockpile of injectable liquid Tigan, a powerful entiemetic used to combat nausea and vomiting. Zofran is another option, although he cautioned that insurers will rarely cover enough for a full application. He advises everyone to have a stash of Lomotil, in case of diarrhea. And if your immediate family has anyone trained in medicine, he even recommends keeping saline bags on hand so that you can hook up an IV set.
While vomiting and diarrhea are not among the most common symptoms of COVID-19, they are present in a certain percentage of cases, and should be particularly feared by patients who require insulin.
There are plenty more details – such as how Dr. Bernstein adjusts insulin to bring glucose levels down during illness – in the video.
New Treatments for COVID-19?
Dr. Bernstein also answered questions about potential new treatments for COVID-19.
“There have been a number of papers demonstrating efficacy of hydroxychloroquine, which is one of several old agents to treat malaria, and then subsequently used to treat rheumatoid arthritis, that they found were effective in stopping the attacks upon the lungs of the COVID virus.”
Dr. Bernstein recommends hydroxychloroquine use, but not prophylactically, only “if I were exposed – that is in contact with someone that I knew that had COVID-19 – or if I started getting the symptoms.”
The media has also been abuzz with reports of a very small study that found that the combination of hydroxychloroquine and the antibiotic azithromycin had remarkable success in treating the virus. Dr. Bernstein is more doubtful about the use of azithromycin, both because the study was so small and because of the additional hazard that an antibiotic can present.
“There’s a tax to azithromycin. If you give a patient azithromycin, the first thing that’s going to happen is that you’re gonna knock out their microbiome… there’s great hazard to this.” The hazard is the increased risk of contracting new illnesses, such as C. diff.”
“I would take at least the hydroxychloroquine, and question mark the azithromycin. So it’s not an easy answer to this particular question … Now we might find that in 2 weeks some big studies will be done and we’ll know that the azithromycin may be a must, or that it’s a no-no. We just don’t know right now.”
But hydroxychloroquine may not be available again any time soon. President Trump recently called hydroxychloroquine “a game changer,” and demand exploded overnight. The latest news is that doctors are hoarding the drug for themselves and that India, a major manufacturer, will cease exporting it altogether. Meanwhile, studies only days old have raised doubts about its efficacy.
There have also been reports that Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) that could either enhance (or inhibit) COVID-19 infection. Dr. Bernstein is taking a wait and see approach:
“I would, at this point of uncertainty, suggest that you continue doing whatever you’re doing. If you’re taking ACE-inhibitors, keep taking them, if you’re not, don’t start them on account of COVID-19. Now, that can change in a week. There could be more data coming up.”
The entire video is well worth a watch for even greater detail on all of these topics. The video was edited by David Dikeman, a teen with Type 1 diabetes who follows Dr. Bernstein’s low carb dietary recommendations.