Therapeutic agents for comorbidities
The therapy of the diabetic patient is complex and should aim not only at controlling glycemic homeostasis but also at a series of comorbidities that can worsen the clinical picture. The medical antihypertensive therapy of choice for the diabetic patient involves the use of ACE inhibitors or angiotensin antagonists2. These drugs not only reduce blood pressure and proteinuria but also slow the progression of diabetic nephropathy. To date there are conflicting and as yet inconclusive results on their use in this period of the COVID-19 pandemic, causing an increase in the risk of infection that they could cause by raising ACE-2 concentrations. It remains to be emphasized that there is currently no clear evidence for or against the use of ACEI/ARB in people with diabetes at risk or infected with Sars-CoV-2. (17). Currently, most international organisations recommend the continuation of ACEI/ARB therapy, unless there are explicit contraindications such as uncontrolled kalaemia or renal stenosis (18)(19). Patients with diabetes undergoing treatment with antiaggregants such as 100mg acetylsalicylic acid should continue to take them. There is currently no evidence of a possible suspension unless there are clear contraindications such as a risk of gastrointestinal bleeding or severe renal impairment. However, in severe COVID-19 patients co-administration of acetylsalicylic acid and corticosteroids or acetylsalicylic acid and heparin may lead to an increased risk of ulcer and gastrointestinal bleeding. In addition, there is currently no direct evidence for statin suspension in patients with diabetes and COVID-19. However, it is of great importance to consider that if the viral infection leads to renal damage (e.g. creatinine clearance <60 ml/min) or liver damage with increased transaminases,(20-21) the statin concentration may increase causing a worsening of the clinical picture with risk of myopathy and liver damage. In addition, antiviral protease inhibitors such as lopinavir in association with statins should not be used because of drug interaction and the risk of increased statin concentrations (22). Therefore for the use of statins we suggest individualized decision on a case by case basis.