Glucose Monitoring and Diabetes Management in the Time of Coronavirus Disease 2019

It is a mistake to try to look too far ahead. The chain of destiny can only be grasped one link at a time. – Sir Winston Churchill

We have learned that the coronavirus disease 2019 (COVID-19) pandemic is presenting the field of diabetes technology with challenges and opportunities. The challenges are difficult to overstate: in the United States, about 34% of patients hospitalized for COVID-19 have pre-existing diabetes, ¹ and patients with diabetes do far worse with COVID-19 than those without. ² The opportunities for diabetes technology are taking the form of stronger and better relationships within the diabetes community, expanded use of continuous glucose monitoring (CGM) and remote monitoring, a greater understanding of the disease as it relates to endocrine and metabolic disruption, and insights that may apply to the next public health crisis.

The very human impact of the pandemic is teaching us more about our commitments and relationships to each other and, importantly, to the communities we serve. In early March, Dexcom instituted work-from-home policies to ensure the safety of its employees; those of us needed on-site are being temperature scanned at the beginning of each shift and are prioritizing social distancing while on site. Interdepartmental relationships are shifting as we realize the extent of our interdependency; we are implementing better ways to onboard new users in hospitals currently inundated with COVID-19 patients. Our relationships with existing customers are no less important, and we are working closely with individuals to ensure that economic disruptions related to the pandemic, such as loss of employment-related health insurance, do not disrupt their access to our products. We have leveraged already-strong relationships with healthcare professionals to aid in the hospital response and have accelerated our contacts with clinicians who are new to CGM. As an example, patients hospitalized with COVID-19 may need to undergo frequent radiographs or CT exams, and we have shared our work on the safety and functional integrity of G6 wearable components ³ that may impact hospital-based care. Finally, our relationships with local and global regulatory authorities are being strengthened as we work toward the shared goals of conserving personal protective equipment, minimizing unnecessary blood draws, and maximizing interpersonal distance in the hospital. The Food and Drug Administration has advised us that they will not object if we provide sensors, transmitters, and technical support to hospitals who want to implement CGM for remote monitoring to support COVID-19-related healthcare efforts. To date, over 100 hospitals and health facilities have contacted us to discuss our continuous and remote glucose monitoring technologies and their potential benefits.

In the future, we predict with certainty that this pandemic will wane. Although its economic, structural, and personal damage will resonate for many years, those who follow us will have opportunities to study COVID-19 and the trade-offs we are making today between likely bad and likely worse outcomes. They will look back on our policy choices related to staying at home and maintaining social distance and will benefit from a vaccine that will be effective and widely deployed. Our future selves will know more about many of the pathophysiological and epidemiological questions that vex us today. Particular questions relate to how the virus interacts with the angiotensin-converting enzyme 2 receptor and disrupts the organs that it infects, and details of the susceptibility of the endocrine pancreas to the virus. Reports that the related severe acute respiratory syndrome coronavirus damages islets and causes acute diabetes ⁴ and that COVID-19 can precipitate diabetic ketoacidosis in newly diagnosed diabetes ⁵ and ketosis in people without diabetes ⁶ offer important clues. We will also learn more about factors that govern the course of COVID-19, the extent to which dysglycemia foreshadows or coincides with the disease, and the extent to which tighter glycemic control improves outcomes.

We will doubtless witness an expansion of the role of CGM in caring for hospitalized patients. This expansion, now in its early stages,^7,8 will likely include patients with acute or critical illness, patients new to or experienced with CGM, and patients with varying insulin needs. The use of connected and interoperable devices in remote diabetes management ⁹ will increase, both in and out of the hospital. As treatment paradigms shift toward remote management and automated insulin delivery systems, the risks and benefits will become more clear and nuanced.

With certainty, we predict that the challenges of using incomplete, noisy, and conflicting data to guide health policy and individual management decisions will persist. With hope, we predict that during the COVID-19 pandemic the role played by magical thinking ¹⁰ will fade, giving way to policies and procedures that are guided by untainted data and focused on improved outcomes for the community of those affected by diabetes.