Exploring the Type 1 Diabetes & COVID-19 Link: A Guide for EMS

It was just another day for paramedic Kenny Parker when he was dispatched to a Charlie-sick call at one of the local high schools in his response area. Upon arriving at the scene, Mike found the young man sitting in the nurse’s office, sweating profusely, feeling tired, and complaining of excessive thirst.

Kenny took a detailed history. A 17-year-old male student had gone to the school nurse after complaining about excessive thirst and frequent urination over the past day. He had been out of school for the past week with a positive COVID-19 infection but with pretty mild symptoms. He had just returned to school today and had drunk several bottles of water in the last few hours and repeatedly went to the restroom. The patient’s pulse rate was rapid at 98 with respiration at 20. His blood pressure was 128/86. The monitor showed a normal sinus rhythm. Pulse oximetry showed 99% on room air and body temperature was 99. His skin was warm and moist. Besides feeling weak, the student, who was also an athlete, looked to be in good shape but had been out of practice for the last week due to his COVID-19. The patient had no significant past medical history or allergies. When Kenny did a glucometer check, he was surprised to find the patient had a blood sugar of 575. He started an IV of normal saline and transported the patient to the local medical center where he was met by his parents and subsequently was diagnosed with Type I diabetes.

What is Type I Diabetes?

Type I diabetes, sometimes known as “juvenile diabetes,” is a chronic condition that affects around 1.25 million Americans. It is an autoimmune disease that occurs when the body's immune system attacks the insulin-producing beta cells in the pancreas, leading to a deficiency of insulin. Insulin is a hormone that helps regulate blood sugar levels by moving glucose from the bloodstream into cells where it can be used for energy. Without enough insulin, glucose builds up in the bloodstream, leading to a condition known as hyperglycemia.

Type I diabetes can occur at any age, but it most commonly develops in children and young adults. Its exact cause is still unknown, but genetics and environmental factors, such as viral infections, may play a role. The COVID-19 pandemic has shed new light on the potential link between viral infections and Type I diabetes.

According to recent studies, COVID-19 infections may increase the risk of developing Type I diabetes. Researchers have found that COVID-19 may trigger an autoimmune response that attacks the pancreas and destroys beta cells. This can lead to the onset of Type I diabetes in individuals who were previously not at risk. 

COVID-19 Connection

A small 2021 study by Genc et al showed that COVID-19 may cause “...beta cell damage, insulin deficiency and [Diabetic Ketoacidosis], and may also trigger autoimmune thyroid diseases such as T1DM and Hashimoto by autoimmune mechanisms.” The study found that juveniles aged 15-20 may be at risk for the development of newly diagnosed Type I Diabetes and DKA as a result of COVID-19 infections.

Another study looked at people who had mild COVID-19 infections in Germany and found that they were 28% more likely to have a new diagnosis of type 2 diabetes compared with people who were never infected. 

A 2022 study in the United States by Rathmann et al also found an increased incidence rate of diabetes in people who had recovered from COVID-19: a 40% increase in risk at least a year after infection. The study authors estimate that two out of every 100 people who are infected with Covid-19 will have a new diagnosis of diabetes. Another 2022 US-based study by Xie and Al-Aly published in the medical journal The Lancet also found that even among people who had low to no risk factors for diabetes, COVID-19 infection led to a 38% increased risk of diabetes afterward. 

According to a March 2023 study by Wang et al, Covid-induced beta cell damage, immune-mediated loss of pancreatic beta cells, and damage to beta cells from the infection of surrounding cells were considered possible mechanisms that could lead to Type I diabetes. The cytokine “storm” that they looked at can cause pancreatitis and subsequent pancreas damage leading to Type I diabetes.

Noting that the development of autoimmune diseases is often a chronic, long-term process, it isn't easy to draw firm conclusions as to whether SARS-CoV-2 causes T1D but early research seems to be pointing in that direction.

Everyday Treatment for Diabetics

There are several effective treatments available for Type I diabetes. The most common treatment is insulin therapy, which involves injecting insulin to replace the deficient hormone in the body. Insulin can be injected using a syringe, insulin pen, or an insulin pump.

Insulin pumps are small, wearable devices about the size of a pack of gum or an old-school pager that deliver insulin continuously throughout the day. They can be programmed to deliver specific amounts of insulin based on a person's individual needs. Insulin pumps are a convenient and effective option for people with Type I diabetes who need frequent insulin injections. They can be worn in a variety of places based on user comfort, including the upper arm, waist, and thigh areas. Common pump brands are Omnipod, MiniMed, and Tandem. Some are known as tethered pumps that use a small tube to connect the pump to the user and are typically worn on the waist. Others are a patch or micro pump that is stuck to the skin and has no tubing. Celebrity fitness instructor Robin Arzon from Peloton has publicly shared about her Type I diabetes diagnosis and wears an Omnipod patch pump during her fitness classes. (She has also run ultramarathons!)

In addition to insulin therapy, there are other treatments available for Type I diabetes. These include continuous glucose monitoring (CGM): CGM devices are wearable sensors that monitor blood sugar levels throughout the day. They provide real-time data and can alert individuals when their blood sugar levels are too high or too low. Common brands are Dexcom, Freestyle Libre, Medtronic, and Eversense. These devices frequently connect with a user's smartphone to monitor blood glucose levels. These devices are also the size of a pack of gum or a small pager and are mounted to the skin, typically on the upper arm or the waist. Diabetics who do not have a GCM have to do frequent finger sticks and measure blood glucose levels with a glucometer.

The future of Type I diabetes treatment looks promising. Researchers are currently working on developing new treatments that could potentially cure Type I diabetes. One approach involves using stem cells to replace the damaged beta cells in the pancreas. Another approach involves using immunotherapy to retrain the immune system to stop attacking the beta cells.

EMS Care for Diabetics

As an EMS provider, your role in treating a diabetic patient is crucial. Refer to your local or state protocols for your exact specifics but the standard EMS protocols for the treatment of diabetics first involve the recognition of symptoms. A patient presenting with confusion, sweating, altered mental status, or fruit-smelling breath can indicate hypoglycemia. A patient presenting with frequent urination and excessive thirst could indicate hyperglycemia. If local protocols allow, confirm blood glucose levels with a glucometer check.

If a patient's blood sugar is low and they have a patent airway, administer fruit juice or oral glucose. If the patient is unconscious or unable to swallow, give them an intramuscular, intranasal, or subcutaneous injection of glucagon or an IV with a D50 bolus. Conversely, if a patient's blood sugar is high, provide supportive care while transporting the patient to the hospital, as well as IV fluid rehydration and insulin if local protocols allow. Supportive oxygen therapy if symptoms or pulse oximetry indicate oxygen deficiency is a further option. Communication with the receiving facility and proper documentation are also essential components of the treatment plan.

Epilogue

Paramedic Kenny Parker followed up on the patient that he had at the high school. After a two-day hospital stay that included insulin injections and patient education, the patient was discharged and referred to an endocrinologist for follow-up and ongoing monitoring. The patient was given a glucose monitoring device that synced with his smartphone and an insulin pump with a remote controller. He has resumed all his activities, including sports. He now wears a medic alert tag and carries carbohydrate snacks whenever he leaves the house. 

Final Thoughts

Type I diabetes is a chronic condition that can be managed with the right treatment and lifestyle modifications. As an EMS provider, it is important to recognize the signs of a diabetic emergency and administer appropriate treatment. Recent studies have shown a rising link between COVID-19 infections and the triggering of Type 1 Diabetes. However, with the advances in diabetes research, there is currently technological support for the disease and hope for a future cure for this condition. 

References: 

Cedars-Sinai Medical Center. (2021, June 29). Verified COVID-19 Infection Increases Diabetes Risk. Retrieved from https://www.cedars-sinai.org/newsroom/verified-covid-19-infection-increases-diabetes-risk/ 

CNN. (2022, March 28). People with diabetes may be at higher risk of severe Covid-19, studies suggest. Retrieved from https://www.cnn.com/2022/03/28/health/diabetes-covid-studies/index.html 

Genç S, Evren B, Bozbay A, Aydın EŞ, Genç Ö, Şahin I. (2022) COULD COVID-19 TRIGGER TYPE 1 DIABETES? PRESENTATION OF COVID-19 CASE PRESENTED WITH DIABETIC KETOACIDOSIS. Acta Endocrinol (Buchar). 2021 Oct-Dec;17(4):532-536. doi: 10.4183/aeb.2021.532. PMID: 35747858; PMCID: PMC9206149. 

Rathmann, W., Kuss, O. & Kostev, K. (2022)  Incidence of newly diagnosed diabetes after Covid-19. Diabetologia 65, 949–954 https://doi.org/10.1007/s00125-022-05670-0 

Today.com. (March 24, 2022). Type 1 diabetes symptoms: Peloton's Robin Arzón opens up about diagnosis. Retrieved from https://www.today.com/health/health/type-1-diabetes-symptoms-pelotons-robin-arzon-opens-diagnosis-rcna21233 

Xie, Y., & Al-Aly, Z. (2022). Risks and burdens of incident diabetes in long COVID: a cohort study. The Lancet Diabetes & Endocrinology, 10(5), 311-321. https://doi.org/10.1016/S2213-8587(22)00044-4 

Yichen Wang, Hui Guo, Gongquan Wang, Jiawei Zhai, Bing Du, COVID-19 as a Trigger for Type 1 Diabetes, The Journal of Clinical Endocrinology & Metabolism, 2023, dgad165, https://doi.org/10.1210/clinem/dgad165 

Barry Bachenheimer, Ed.D, NREMT/FF is a frequent contributor to EMS World and is a practicing EMS provider with 37 years of experience.