Personal Experience With COVID-19 and Diabetes in the South of France: Technology Facilitates the Management of Diabetes in Disruptive Times

I have learned that patients with Type 1 diabetes using insulin pumps and continuous or flash glucose monitoring (CGM/FGM) are quite able to manage their insulin therapy by themselves in a context of minimized support from the health care team while their life is dramatically disrupted. ¹ By chance, the South of France region where I practice has been relatively saved by the COVID-19 epidemic. Whereas the viral tsunami strongly impacted the Eastern part of the country and the Paris neighborhood due to the high number of early cases based on local clusters, ² the decision of national confinement of all people at home from middle-March allowed an efficient limitation of the epidemic in our Mediterranean region. The Pyrenees and Alp mountainous zones on our borders also likely limited the fluxes of contamination from Spain and Italy where the corona virus hurt so many people. Nevertheless, the confinement led us to cancel all our face-to-face consultations and reduced our staff to a tight minimum to take care of emergencies only. Although most of our patients—we take care of an active file of 1200 patients treated by insulin pumps—had to stop their activities and stayed at home in anxiety and fear of being contaminated, two factors promoting hyperglycemia, we faced almost no emergency. Likely the structured education delivered to our patients when they moved to pump therapy and during their follow-up helped them to cope with their new stressful life conditions by increasing their insulin doses as needed. Besides, we could see how the combination of CGM/FGM and insulin pump therapy facilitated both the assessment of our patients’ glucose disorders via their email messages including their last data downloads and the fast efficacy of the treatment adjustments we recommended. Whereas telemedicine remained a limited component of our care before the epidemic, it became in a flash usual practice. Thanks to the data sent by using the various FGM/CGM download services (LibreView, Clarity, and CareLink), we could get from our patients a quick and clear view of glucose disturbances. Moreover, our suggested adaptations of insulin pump basal rates and bolus appeared to be efficient in a few hours with no need for urgent outpatient visits or hospitalizations. So far, no diabetic ketoacidosis occurred in spite of the frequent higher insulin needs. Of note, our specific French system of home care providers for people treated by insulin pumps, although considered as expensive in periods of calm waters, appeared to be quite useful for people who struggled for downloading their FGM/CGM data or faced with pump hardware failures. ³ A simple email to the network of home care providers’ nurses prompted a home visit to the patients in hazardous situations. The home care services could download patients’ FGM/CGM data and send them to us by email in less than three hours in most cases, in spite of the confinement conditions. When needed, a new insulin pump could be brought to the patient in a similar short delay.

As far as I am aware, we met no serious case of COVID-19 in our patient population so far (let’s cross our fingers because the virus is still prowling!). Effective glucose control is well documented as a way to reduce the vulnerability of people with diabetes to infections in critical conditions. ⁴ Moreover, it was recently reported that poorly controlled diabetes is a risk factor for more severe cases of COVID-19 infections. ⁵ Even if not all our patients with insulin pumps meet the optimal glucose targets, their average glycated hemoglobin levels are lower on the long term than when they were initiated to insulin pump therapy. ⁶ Altogether, the combination of a structured patient education, diabetes and information and communication technologies and an available network supporting collaboration between hospital and homecare professionals, forms an ecosystem that protects patients with diabetes during stormy times.

In the future I predict that the health care system dedicated to patients with diabetes will finally benefit from this unexpected experience. Indeed the more energy and means are dedicated to improve average diabetes care in quiet times, the better are the outcomes in a critical environment thanks to the higher ability to manage diabetes. Whereas diabetes technologies are frequently considered as too expensive to be prescribed to many patients, the current experience with the COVID-19 clearly demonstrates that the time and money spent to allow patients reaching a better glucose control and an improved confidence in coping with adversity are profitable investments. This is true both in terms of reduction of emergency care and for a better acceptance of living with a more demanding chronic disease under a black sky. Once again, the old Latin adage si vis pacem para bellum should prevail.