Increased Severity of COVID-19 in Patients with Newly Diagnosed Diabetes: A Public Health Priority

Thirunavukkarasu Sathish1, *
1 Department of Family and Preventive Medicine, School of Medicine, Emory Global Diabetes Research Center, Woodruff Health Sciences Center, Emory University, Atlanta, GA, USA

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Creative Commons License
© 2023 Thirunavukkarasu Sathish

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Department of Family and Preventive Medicine, School of Medicine, Emory Global Diabetes Research Center, 100 Woodruff Health Sciences Center, Emory University, Atlanta, GA 30322, USA; E-mail: sathish.thirunavukkarasu@emory.edu

Dear Editor,

The recently published article by Maheshwari A et al. [1] adds to the existing body of evidence that coronavirus disease-2019 (COVID-19) patients with newly diagnosed diabetes (NDD) experience more severe illness than those with preexisting diabetes (PD) [2-5]. However, the mechanisms explaining this surprising observation have not yet been completely identified ever since it was first reported by Li H et al. [6] during the pandemic's very early phase (Jan to Mar 2020).

In the study by Maheshwari A et al. of 1630 adults (≥18 years), 958 (58.8%) had PD, 224 (13.7%) had NDD, and 448 (27.5%) had no diabetes. Compared with patients with NDD, those with PD had significantly higher levels of parameters that contribute to the increased severity of COVID-19: mean random blood glucose (240.4 mg/dl vs. 309.5 mg/dl), HbA1c (6.7% vs. 8.1%), and age (50.8 vs. 52.7 years), and males (59.8% vs. 63.6%) and ≥4 comorbidities (0.9% vs. 21.1%). On the contrary, patients with NDD were significantly more likely to be hospitalized for COVID-19 treatment (82.6% vs. 45.4%), have a high chest computed tomography severity score (47.6% vs. 15.1%), and require oxygen support (74.0% vs. 42.7%) and steroids (85.3% vs. 74.4%) compared to those with PD. The authors, however, did not provide data on inflammatory markers, coagulation indices, and the use of anti-diabetes medications during hospitalization. Guidelines recommend using dipeptidyl peptidase-4 (DPP4) inhibitors and glucagon-like peptide 1 (GLP1) analogues (although with caution of avoiding dehydration) [7], as these drugs may reduce COVID-19 severity by their anti-inflammatory actions [8].

Possible mechanisms explaining the increased risk of severe COVID-19 in NDD patients include stress hyperglycemia, modulation of immune and inflammatory responses by acute hyperglycemia, lack of protective effect from metformin (as in PD patients), upregulation of angiotensin-converting enzyme 2 (ACE2) receptors on cells due to acute hyperglycemia (thereby facilitating virus entry into the cells), and occult or masked multi-organ damage due to the undiagnosed nature of NDD [4-6, 9-14].

An estimated 240 million people live with undiagnosed diabetes globally, which translates to almost one-in-two adults with diabetes being unaware of their condition [15]. More worryingly, nearly 90% of people with undiagnosed diabetes live in low- and middle-income countries such as India. Undiagnosed diabetes, in addition, to causing several diabetes-related complications [15], results in increased severity and mortality from COVID-19. Thus, detecting people with undiagnosed diabetes and treating them early is now a public health priority more than ever.


NDD = Newly Diagnosed Diabetes
COVID-19 = Coronavirus Disease-2019
PD = Preexisting Diabetes
DPP4 = Dipeptidyl Peptidase-4
GLP1 = Glucagon-like Peptide 1
ACE2 = Angiotensin-converting Enzyme 2


The author declares no conflict of interest financial or otherwise.


Declared none.


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