Future perspectives
The appropriate management of patients with diabetes and COVID-19 is not yet clear. Patients with diabetes should be declared as risk group for severe disease and worse outcomes. Future research may help develop a scoring system to identify vulnerable patients who may benefit from aggressive treatment or intensive support from outset to limit deterioration. Although a specific anti-viral drug is urgently required, a multi-target agent is also required to help regulate the dysregulated neuro-endocrine-immune system that is common in metabolic disease, including diabetes, cardiovascular disease, atherosclerosis, insulin resistance, hypertension, dyslipidaemia and obesity. The role of hypoglycaemic medications such as dipeptidyl peptidase-4 (DPP-4) inhibitors, which may act as receptor for COVID-19 and the glucagon-like peptide-1 receptor agonist (GLP-1 RA), that may reduce inflammation, will need further investigation. 55, 56 Similarly, the role of RAAS inhibitors with COVID-19 infection need exploration. It is not yet clear why insulin users had worse prognosis compared with other hypoglycaemic medications. 16 Whilst insulin users tend to have advanced disease with long duration of diabetes, prevalent complications and co-existing comorbidities to explain their worse outcome, further clarification is required. The role of hyperglycaemia, hyperinsulinaemia and hypoglycaemic agents in the pathogenesis of COVID-19 and how diabetes affects the efficacy of future vaccines and antiviral agents currently in trials are warranted. COVID-19 related mortality was reported to be higher in the Black and Asian ethnic groups with diabetes compared with the White population. 17Therefore, future research is needed to provide a better understanding of the potential differences in genetic predispositions across populations and the underlying pathophysiological mechanisms. Finally, novel ways to deliver care to patients with diabetes using telehealth, remote patient monitoring and wearable technologies are required.