Elderly diabetes meets the new crown, how to use the right two-pronged medication?

After three years of prevention and control, the new crown virus infection has finally ushered in a new stage
of "Class B tube".
Since middle-aged and elderly patients with chronic underlying diseases are the main group of new crown infection deaths, the mortality rate of diabetic patients is significantly higher than that of non-diabetic people ^[1], coupled with the rising number of infections, many diabetic patients, especially elderly patients and their families, began to panic, antiviral treatment drugs, such as Paxlovid (nematevir tablets/ritonavir tablets), have also become the "material" that people rush to buy
。

So, when diabetes meets the new crown, how to correctly apply antiviral drugs like Paxlovid? In this special case, what else should be paid attention to in the daily hypoglycemic treatment of diabetic patients? Next, please take a look at the editor's
inventory one by one.

Rationally, diabetic people can choose Paxlovid appropriately and reasonably

Paxlovid is suitable for adults with mild to moderate incidence within 5 days of onset and risk factors for
progression to severe disease.
Nematevir 300 mg and ritonavir 100 mg are required for use once every 12 hours for 5 days^[2].

It can be seen that Paxlovid has requirements for the time of onset, and if there are no risk factors for severe disease, it does not need to be used
.

People with diabetes are at high risk of severe disease from the new crown
.
A previous study of 1122 patients with new crown infection in the United States showed that the mortality rate of new crown patients with diabetes increased by 4 times compared with new crown patients without diabetes ^[3].

A meta-analysis of 16,003 patients with new coronavirus from 33 studies showed a twofold increased risk of progression to critical illness or death in patients with diabetes ^[4].

Previously, studies analyzed the risk factors for progression to critical disease in patients with new crown diabetes and showed that fever and C-reactive protein and increased fasting blood glucose were independent risk factors for progression to critical disease in patients with new crown diabetes and should attract clinical attention ^[5].

For diabetic patients who are at risk of severe disease and do not have contraindications to Paxlovid, Paxlovid
can be considered as appropriate according to the patient's condition and wishes.

As far as commonly used hypoglycemic drugs are concerned, Paxlovid can be used in combination with metformin, acarbose, dipeptidyl peptidase IV inhibitors (DPP-4i) and other drugs, so there is no need to stop the drug
for diabetic patients who are using these hypoglycemic drugs, including elderly patients.

However, in DPP-4i drugs, if linagliptin, sitagliptin, etc.
are used, dose adjustment is not required; If saxagliptin is used, the recommended dose of saxagliptin when used in combination is 2.
5 mg/day ^[6].

When combined with glibenclamide, nateglinide, and repaglinide, it is recommended to monitor blood glucose and, if necessary, adjust the dose ^[6].

Foresight, diabetes combined with new crown infection, sugar control is essential

The adverse effects of long-term high blood sugar on the human immune system make diabetic patients more prone to various infections, which in turn aggravates diabetes ^[1] and forms a vicious circle
.
Therefore, the treatment of diabetes combined with new crown infection can not only focus on the use of drugs such as Paxlovid to treat new crown infection, but also pay attention to sugar
control.
During the new crown epidemic, blood glucose management in diabetic patients is particularly important, because it is related to the prognosis and outcome
of patients.

First of all, it is necessary to set individualized glycemic control goals for patients with diabetes and new crown infection, especially elderly patients ^[7]:

1.
Control target fasting blood glucose of light/ordinary elderly diabetic patients is about 7mmol/L;

2.
Patients with severe/critical disease should implement the goal of relaxed treatment of inpatient blood glucose, that is, fasting or preprandial blood glucose is 7.
8-10.
0mmol/L, and 2h after prandial or random blood glucose is maintained at 7.
8-13.
9mmol/L
.

3.
Severe patients should not < 7.
8mmol/L
because the symptoms of hypoglycemia are often not obvious.

Secondly, elderly diabetic patients with mild/common new crown infection need to adjust the hypoglycemic plan according to the doctor's advice, and cannot stop or change the drug without authorization ^[7].

Moreover, it is necessary to strictly grasp the contraindications
of hypoglycemic drugs.
Metformin can be used in ambulatory patients; Sulfonylurea-lowering drugs are prone to hypoglycemia in elderly patients; Thiazolidinediones should be used with caution in patients with heart failure and hepatic insufficiency; Glinides can be used in patients with renal insufficiency, but be alert to the risk of hypoglycemia; α-glycosidase inhibitors should be used with caution in patients with severe gastrointestinal dysfunction ^[7]; Some hypoglycemic drugs are estimated to have a glomerular filtration rate (eGFR) of less than 45ml·^min-1· (1.
73m²)-1 needs to be discontinued, such as metformin, and some oral hypoglycemic drugs, such as DPP-4i, etc.
, suitable for the population has expanded ^[1].

It should be noted that there are many kinds of DPP-4i currently on the market in China, and in patients with renal insufficiency, including elderly patients, when using sitagliptin, saxagliptin, alogliptin and vildagliptin, attention should be paid to reducing the dose of the drug according to the drug instructions, while lindagliptin in patients with renal insufficiency does not require dose adjustment, and the CARMELINA study showed that lindagliptin did not increase renal composite outcomes (renal death, Risk of progression to end-stage renal disease or persistent decreased eGFR ≥40 percent), with good renal safety ^[8].

The "Clinical Pharmacy Guidelines for Antiviral Treatment of Novel Coronavirus Pneumonia" also recommends that diabetic patients can continue to use DPP-4i [^6]
after infection with the new crown.
Even when access to healthcare is inconvenient, linagliptin provides safe and easy treatment options for patients to help optimize diabetes management
during the pandemic.