Outcomes of Diabetic Patients with Covid-19

Outcomes of Diabetic Patients with Covid-19


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Outcomes of Diabetic Patients with Covid-19


Thirty peer-reviewed articles obtained from the PubMed database were reviewed. They revealed that between 25% and 50% of Covid-19 patients had diabetes mellitus (DM), and were at a higher risk of adverse clinical outcomes, admission into the intensive care units, respiratory support using mechanical ventilators, and death. The development of diabetic ketoacidosis (DKA) among diabetic patients worsened their clinical outcomes when they contracted Covid-19. Mortality rate for diabetic Covid-19 patients ranged between 5.3% and 42.3%. Therefore, the literature demonstrated that diabetes heighted the adverse outcomes in covid-19 patients.   


Covid-19 has affected different people differently, with those with predisposed health conditions fairing poorer than their healthier counterparts. Diabetes is one health condition that appears to aggravate the effects of Covid-19 on patients. As more Covid-19 patients with diabetes present themselves to hospital due to the severity of their conditions, more is being learned continuously about how covid-19 is affecting people that are living with diabetes. Nassar et al. [1] revealed that between 0.15 and 28.98% of Covid-19 patients had type-1 diabetes mellitus. However, Selvin and Juraschek [2] argued that early studies were challenged by the lack of meticulous epidemiologic design and analysis, thus limiting the knowledge of the effect on diabetic patients. In this regard, new information related to the outcomes of diabetic patients with Covid-19 continues to appear in literature. This literature review samples some of the relevant publications addressing the outcomes of this patient population. The review is organized topically and will address the literature related to the hospitalization of diabetic Covid-19 patients, the severe pneumonia they encounter, diabetic ketoacidosis, and death.

Materials and Methods

The literature comprised of peer-reviewed journal articles, conference papers, books, organsational publications, and expert opinions that are readily available over the internet. Google Scholar was the search engines used to query online databases for relevant and current publications. It was used to query the PubMed database for the publications exclusively. The keywords used in the online search included, covid-19, diabetes, diabetic ketoacidosis, pneumonia, hospitalization, and mortality, which were used in different combinations in search phrases such as Covid-19 and diabetes mellitus, Covid-19 patients with diabetes, outcomes of diabetic covid-19 patients, diabetic ketoacidosis in covid-19 patients, and mortality of diabetic covid-19 patients, hospitalization of diabetic Covid-19 patients, pneumonia in diabetic Covid-19 patients, risk factors for covid-19 patients with diabetes. Literature published in the last 3 years was selected to ensure the information contained was current and relevant. Besides, only literature published in English was accepted. The literature screening process is summarized in figure 1.

Figure 1: Publication screening process


Thirty (30) publications that fitted the search criteria were retrieved from online databases. The reviewed sources were published between 2020 and 2021, which is summarized in table 1.

Table 2. Year of publication of the sources

YearNo. of Publications

General Discussion

Hospitalization of Covid-19 patients

Covid-19 patients with diabetes often deteriorate fast healthwise if their diabetes or Covid-19 infection is not managed promptly and effectively. A study of 113 Covid-19 patients from 52 locations in the United States by O’Malley et al. [3] revealed that about half of them were hospitalised and 5 passed on, which is about 5% of the patient population. Most of the hospitalised patients were older, African Americans, lacked public health insurance, had hypertension, and unlikely to monitor their glucose continuously or use insulin pumps.

A study conducted by Abu-Farha et al. [4] revealed that of the elderly people that had been infected with Covid-19, more than a quarter of them (26.8%) had diabetes mellitus.  Similarly, a comprehensive literature review by Yu et al. [5] revealed that obesity was a risk factor that aggravated the clinical outcomes of patients with Covid-19, increasing their likelihood of developing severe disease and hospitalization. Apicella et al. [6] also included age, gender, and ethnicity as other factors that worsened the outcomes of diabetic Covid-19 patients. In the same breath, according to Lim et al. [7], it has been found that Covid-19 could increase the risk of developing hyperglycaemia in patients. This led Reddy et al. [8] to conclude that covid-19 and diabetes mellitus related bi-directionally as one presented a risk factor to the other.

In addition, according to Shang et al. and Roncon et al., diabetic patients were more likely to be admitted into the intensive care unit upon contracting Covid-19 and were more likely to die from it compared to those that did not have covid-19 [9][10]. This has been supported by Zhang et al. [11], who indicated the need to monitor cardiac troponin I (cTnI) in diabetic patients with Covid-19 because they exhibited adverse clinical outcomes. Similarly, Shang et al. [9] revealed that Covid-19 patients with diabetes, particularly those that required insulin therapy required more attention at hospital because of the high risk of adverse outcomes. Rawshani [12] reported that patients with type-II diabetes were at a higher risk of being hospitalised and admitted into the intensive care unit compared to those with type-I diabetes due to complications presented by Covid-19. Davenport [13] revealed that half of the diabetic patients with Covid-19 would be discharged from hospital while another 20% will have died after being hospitalised for a month. A study by Barron et al. [13] revealed that that chances of death of Covid-19 patients with type 1 and type 2 diabetes were 138 and 260 deaths per 100,000 patients, respectively. Altogether, the literature indicated that diabetic patients had a high risk of being hospitalised when they contracted Covid-19.  

Severe Pneumonia in Covid-19 patients

Patients with severe covid-19 related pneumonia are likely to be hospitalized and their outcomes are worse if the patients are diabetic. Nafakhi et al. [14] found that of the 192 Iraqi patients with covid-19 pneumonia that he studies, 67 were diabetic and insulin use aggravated lung injury and post covid-19 recovery. In this regard, Von der Thüsen and van der Eerden [15] revealed that although covid-19-induced pneumonia ranged from mild to severe illness accompanied by acute hypoxemic respiratory failure, diabetic patients had a higher risk of developing severe pneumonia, thus requiring ventilation and intensive care compared to non-diabetic patients. In the same vein, Pal, Bhadada, and Misra [16] justified the need to vaccinate diabetic patients with Covid-19 against pneumococcal pneumonia because of their high risk of developing severe pneumonia.  However, Zhao et al [17] indicated that covid-19 induced and non-covid-19 induced pneumonia were indistinguishable at their onset and often presented as cough and fever. This made it difficult to predict the Covid-19 patients that would develop severe pneumonia, even when they had diabetes as comorbidity. Altogether, this literature indicated that diabetic patients had an elevated risk of developing severe pneumonia upon contracting Covid-19.

Diabetic Ketoacidosis in Covid-19 patients

Diabetic ketoacidosis is a condition associated with severe covid-19 outcomes and lengthy hospitalization. Pal et al. [18] revealed that some Covid-19 patients reported diabetic ketoacidosis (DKA), a condition that is characterized by the body producing high ketone quantities due to the inability to produce sufficient insulin. Similarly, Boddu, Aurangabadkar and Kuchay [19] indicated that the coronavirus could trigger several diabetic ketoacidosis in patients with new-onset diabetes although it was not clear whether it induced type-I or type-II diabetes. In the same vein, Kuchay et al. [20] indicated that such patients did not need to have a history of diabetes to experience diabetic ketoacidosis. Therefore,

From this background, Guo et al. [21] concluded that there was a strong and evident correlation between severe covid-19 and diabetic ketoacidosis because the viral infection precipitated a hyperglycemic state in patients and the onset of ketoacidosis in diabetic and not diabetic patients, often with fatal outcomes. In this regard, Barrett et al. [22] revealed that patients with type-I diabetes were at a higher risk of intensive care unit admission and mechanical ventilation after being infected with covid-19 compared to those with type-II diabetes primarily because they developed diabetic ketoacidosis. Nonetheless, Palermo, Sadhu and McDonnell [23] indicated that diabetic ketoacidosis was a preventable condition, which needed to be address in Copvid-19 patents to reduce progression to severe disease and death. With this hopeful finding, Orioli et al. [24] revealed that the continuation of antihypertensive medication that interacted with the renin-angiotensin-aldosterone system was not discounted although SGLT2 inhibitors and metformin needed to be discontinued in patients with severe Covid-19 due to the heightened risk of ketoacidosis and lactic acidosis.  Altogether, this literature indicated that diabetic patients had a higher risk of developing diabetic ketoacidosis when they contracted Covid-19, which increased the likelihood of fatal outcomes.

Death from Covid-19 Complications

Death associated with Covid-19 complications commences with cell deaths progressing to eventual mortality of the patient. The eventual death of Covid-19 patients progresses through a severe disease phase that is indicated by elevated levels of inflammation serum biomarkers, such as ferritin, innteleukin-6, and C-reactive protein, which indicate a proinflammatory state. The proinflammatory state is more pronounced and accelerated in diabetic patients leading to their high in-hospital mortality. Similarly, Steenblock et al. [25] found out that patients with pre-existing diabetes experienced necrotic cell death, which contributed to diverse levels of metabolic dysregulation among Covid-19 patients, which influenced the severity of the coronavirus infection.

Diabetic patients have been associated with a high mortality rate among covid-19 patients. This was confirmed from a meta-analysis conducted by Kumar et al. [26], who revealed that diabetic patients were twice more likely to experience severe covid-19 and die from covid-19-related complications than those without diabetes. A similar study by Huang, Lim and Pranata [27] indicated diabetes was associated with acute respiratory distress syndrome, severe Covid-19 complications, and high mortality rate. Acharya et al. [28] study findings qualify these conclusions by revealing that the high mortality rate among hospitalized diabetic patients can be predicted using risk factors such as high levels of serum lactate dehydrogenase (LDH) and advanced age of higher than 70 years. Altogether, Zhu et al. [29] noted that that the survival rate of covid-19 patients with well-controlled blood sugar was 98.85 while 11% of patients with poorly-controlled blood sugar were likely to die from the virus. Abbasi et al. [30] placed the Covid-19-related mortalities in the general population at between 1% and 15%, which goes up to between 17% and 38% in older patients, with diabetic patients experiencing fatalities between 5.3% and 42.3%. In conclusion, what this literature demonstrates is that the mortality rate of covid-19 patients was elevated when they had diabetes.


The literature revealed that the relation between diabetes and Covid-19 was bidirectional as one condition contributed to the onset or worsening of the other. In addition, Covid-19 patients with diabetes experienced worse clinical outcomes that those that were not diabetic. The outcomes were regardless on whether the patient has a history of diabetes or have newly-acquired the condition. Also, patients with type-II diabetes tended to have more adverse outcomes compared to those with type-I diabetes because of their age. Specifically, Covid-19 patients with type-II diabetes tended to be older and frailer, thus experiencing more severe clinical outcomes compared to those with type-I who tended to be younger.


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[2] Selvin E, Juraschek SP. Diabetes epidemiology in the COVID-19 pandemic. Diabetes Care. 2020 Aug 1;43(8):1690-4.

[3] O’Malley G, Ebekozien O, Desimone M, Pinnaro CT, Roberts A, Polsky S, Noor N, Aleppo G, Basina M, Tansey M, Steenkamp D. COVID-19 hospitalization in adults with type 1 diabetes: results from the T1D Exchange Multicenter Surveillance Study. The Journal of Clinical Endocrinology & Metabolism. 2021 Feb;106(2):e936-42.

[4] Abu-Farha M, Al-Mulla F, Thanaraj TA, Kavalakatt S, Ali H, Abdul Ghani M, Abubaker J. Impact of diabetes in patients diagnosed with COVID-19. Frontiers in Immunology. 2020:3112.

 [5] Yu W, Rohli KE, Yang S, Jia P. Impact of obesity on COVID-19 patients. Journal of Diabetes and its Complications. 2021 Mar 1;35(3):107817.

[6] Apicella M, Campopiano MC, Mantuano M, Mazoni L, Coppelli A, Del Prato S. COVID-19 in people with diabetes: understanding the reasons for worse outcomes. The Lancet Diabetes & Endocrinology. 2020 Sep 1;8(9):782-92.

[7] Lim S, Bae JH, Kwon HS, Nauck MA. COVID-19 and diabetes mellitus: from pathophysiology to clinical management. Nature Reviews Endocrinology. 2021 Jan;17(1):11-30.

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 [10] Roncon L, Zuin M, Rigatelli G, Zuliani G. Diabetic patients with COVID-19 infection are at higher risk of ICU admission and poor short-term outcome. Journal of Clinical Virology. 2020 Jun 1;127:104354.

 [11] Zhang N, Wang C, Zhu F, Mao H, Bai P, Chen LL, Zeng T, Peng MM, Qiu KL, Wang Y, Yu M. Risk factors for poor outcomes of diabetes patients with COVID-19: A single-center, retrospective study in early outbreak in China. Frontiers in Endocrinology. 2020:695.

 [12] Rawshani A, Kjölhede EA, Rawshani A, Sattar N, Eeg-Olofsson K, Adiels M, Ludvigsson J, Lindh M, Gisslén M, Hagberg E, Lappas G. Severe COVID-19 in people with type 1 and type 2 diabetes in Sweden: A nationwide retrospective cohort study. The Lancet Regional Health-Europe. 2021 May 1;4:100105.

 [13] Barron E, Bakhai C, Kar P, Weaver A, Bradley D, Ismail H, Knighton P, Holman N, Khunti K, Sattar N, Wareham NJ. Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a whole-population study. The lancet Diabetes & endocrinology. 2020 Oct 1;8(10):813-22.

[14] Nafakhi H, Alareedh M, Al-Buthabhak K, Shaghee F, Nafakhi A, Kasim S. Predictors of adverse in-hospital outcome and recovery in patients with diabetes mellitus and COVID-19 pneumonia in Iraq. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2021 Jan 1;15(1):33-8.

[15] Von der Thüsen J, van der Eerden M. Histopathology and genetic susceptibility in COVID‐19 pneumonia. European Journal of Clinical Investigation. 2020 Jul;50(7):e13259.

[16] Pal R, Bhadada SK, Misra A. COVID-19 vaccination in patients with diabetes mellitus: Current concepts, uncertainties and challenges. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2021 Mar 1;15(2):505-8.

[17] Zhao D, Yao F, Wang L, Zheng L, Gao Y, Ye J, Guo F, Zhao H, Gao R. A comparative study on the clinical features of coronavirus 2019 (COVID-19) pneumonia with other pneumonias. Clinical Infectious Diseases. 2020 Jul 28;71(15):756-61.

[18] Pal R, Banerjee M, Yadav U, Bhattacharjee S. Clinical profile and outcomes in COVID-19 patients with diabetic ketoacidosis: a systematic review of literature. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2020 Nov 1;14(6):1563-9.

[19] Boddu SK, Aurangabadkar G, Kuchay MS. New onset diabetes, type 1 diabetes and COVID-19. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2020 Nov 1;14(6):2211-7.

[20] Kuchay MS, Reddy PK, Gagneja S, Mathew A, Mishra SK. Short term follow-up of patients presenting with acute onset diabetes and diabetic ketoacidosis during an episode of COVID-19. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2020 Nov 1;14(6):2039-41.

[21] Guo W, Li M, Dong Y, Zhou H, Zhang Z, Tian C, Qin R, Wang H, Shen Y, Du K, Zhao L. Diabetes is a risk factor for the progression and prognosis of COVID‐19. Diabetes/Metabolism Research and Reviews. 2020 Oct;36(7):e3319.

[22] Barrett CE, Park J, Kompaniyets L, Baggs J, Cheng YJ, Zhang P, Imperatore G, Pavkov ME. Intensive care unit admission, mechanical ventilation, and mortality among patients with type 1 diabetes hospitalized for COVID-19 in the US. Diabetes Care. 2021 Aug 1;44(8):1788-96.

[23] Palermo NE, Sadhu AR, McDonnell ME. Diabetic ketoacidosis in COVID-19: unique concerns and considerations. The Journal of Clinical Endocrinology & Metabolism. 2020 Aug;105(8):2819-29.

[24] Orioli L, Hermans MP, Thissen JP, Maiter D, Vandeleene B, Yombi JC. COVID-19 in diabetic patients: Related risks and specifics of management. In Annales d’endocrinologie 2020 Jun 1 (Vol. 81, No. 2-3, pp. 101-109). Elsevier Masson.

[25] Steenblock C, Richter S, Berger I, Barovic M, Schmid J, Schubert U, Jarzebska N, von Mässenhausen A, Linkermann A, Schürmann A, Pablik J. Viral infiltration of pancreatic islets in patients with COVID-19. Nature Communications. 2021 Jun 10;12(1):1-2.

[26] Kumar A, Arora A, Sharma P, Anikhindi SA, Bansal N, Singla V, Khare S, Srivastava A. Is diabetes mellitus associated with mortality and severity of COVID-19? A meta-analysis. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2020 Jul 1;14(4):535-45.

[27] Huang I, Lim MA, Pranata R. Diabetes mellitus is associated with increased mortality and severity of disease in COVID-19 pneumonia–a systematic review, meta-analysis, and meta-regression. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2020 Jul 1;14(4):395-403.

[28] Acharya D, Lee K, Lee DS, Lee YS, Moon SS. Mortality rate and predictors of mortality in hospitalized COVID-19 patients with diabetes. In Healthcare 2020 Sep (Vol. 8, No. 3, p. 338). Multidisciplinary Digital Publishing Institute.

[29] Zhu L, She ZG, Cheng X, Qin JJ, Zhang XJ, Cai J, Lei F, Wang H, Xie J, Wang W, Li H. Association of blood glucose control and outcomes in patients with COVID-19 and pre-existing type 2 diabetes. Cell Metabolism. 2020 Jun 2;31(6):1068-77.

[30] Abbasi E, Mirzaei F, Tavilani H, Khodadadi I. Diabetes and COVID-19: Mechanism of pneumonia, treatment strategy and vaccine. Metabolism Open. 2021 Sep 1;11:100122.

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