**5. Complications**

Apart from the known pulmonary complications, extra pulmonary complications from COVID-19 include neurological, cardiovascular, gastro-intestinal, renal, endocrine and dermatological complications are being reported [35]. Due to COVID-19 infection, there have been increased risk of hyperglycaemia, euglycaemic ketosis and diabetic ketoacidosis (DKA) [35]. With COVID-19 infection, there is a risk of atypical presentations of complications such as DKA or mixed hyperosmolar states with associated increased mortality. A retrospective case series confirmed that PWD are at a risk of combined DKA and HHs with COVID-19 infection [36]. Data from our own centre has shown that DKA in T2DM is increased significantly and that the frequency of HHS increased seven fold during the first Covid pandemic in the UK [37]. Fluid management is a challenge in such patients especially in case of renal impairment and ARDS should be avoided. Guidelines for management of DKA is available on the Diabetes UK website and it is worth remembering that euglycaemic DKA can occur in patients taking SGLT2i or in pregnancy [14]. In a whole population study assessing risks of in-hospital death in England, people with T1DM were found to be three-and-a-half times more at risk of dying from COVID-19 infection, while people with T2D are at twice the risk of dying than people without diabetes [38]. Hence, continued measures to mitigate the risks of people with diabetes of becoming seriously ill or dying due to COVID-19 infection is warranted.
