**4. Management of type 2 diabetes and COVID-19 infection**

Diabetes UK, a British-based patient, healthcare professional and research charity, has provided advice for healthcare professionals on COVID-19 and inpatient diabetes care on their website and topics include front door guidance, managing inpatient hyperglycaemia, dexamethasone therapy and safe discharge endorsed by the Joint British Diabetes Society (JBDS) and Association of British Clinical Diabetologists (ABCD) [14].

Front door guidance is available for inpatients [13]. An ABCDE (Airway, breathing, circulation, disability and exposure) approach is warranted initially if patient is unwell, CBG> 12 mmol/L or known diabetes. Aim is rule out DKA, HHS and watch out for new presentation of diabetes, sepsis, steroid use, uncontrolled diabetes or delayed and missed treatment of diabetes [13]. Be aware of the possibility of euglycaemic DKA. Stop Metformin and SGLT2 inhibitors on admission. Fluid requirements may differ in patients with COVID-19 infection and have to be tailored individually due to ARDS, cardiac involvement or AKI. Contact the diabetes specialist team and early involvement of critical care team where appropriate.

Target glucose levels are 6–10 mmol/L, and up to 12 mmol/L is acceptable. The guidance for managing inpatient hyperglycaemia should be used if glucose levels are >12 mmol/L and a corrective dose is appropriate and the patient is not in DKA or HHS [14]. It provides information for patients on insulin and insulin naïve patients too, regarding insulin dose adjustment as while recovering from COVID-19 related insulin resistance, doses may require rapid reduction to avoid hyperglycemia [14]. Initiation of IV insulin with monitoring of blood glucose, electrolytes, pH and ketones should be done as appropriate. Blood ketones <0.6 mmol/L is safe, blood ketones 1.5–2.9 mmol/L signifies increased risk of DKA [13], and if 3 mmol/L or greater, then check pH and bicarbonate for possibility of DKA [13].

If patients unable to manage insulin pump start on variable rate intravenous insulin infusion (VRII) or subcutaneous (S/C) insulin. For S/C insulin find out the total daily insulin dose and if not available can be calculated as 0.5 units multiplied by weight. Half this dose is given as basal and remaining half as bolus dose divided by 3 to give the meal time dose [13]. If patient is placed in prone position, feeding may be affected and that needs to be taken into account while dosing insulin.

Continuous glucose monitors (CGMs) and flash glucose monitoring (FGM) can be left on but capillary blood glucose monitoring must still continue. For magnetic imaging such as MRIs, these devices including pumps should be removed [13]. Always check the feet on admission to look for foot infection and rule out critical limb ischaemia.
