As the rates of infection from the novel coronavirus disease-2019 (COVID-19) continue to rise, clinician scientists from the Endocrine Society felt it timely to highlight how clinicians should best care for their patients with endocrine-related conditions as well as how the field might best contribute to fighting the global pandemic. The commentary from the society was published in The Journal of Clinical Endocrinology & Metabolism.
The authors noted that patients treated with glucocorticoids who have primary or secondary adrenal insufficiency should take precautions by following sick day rules. Patients with a dry, continuous cough and fever should double their daily oral glucocorticoid dose immediately and continue until fever subsides. Extreme cases with symptoms such as vomiting and diarrhea should seek urgent medical care and be treated with parenteral glucocorticoids.
The authors suggested that it is logical, if not essential, to identify all patients taking corticosteroids as high risk, as the prevalence of adrenal insufficiency in patients taking chronic therapeutic corticosteroids is high (approximately 50%). Currently, little evidence exists to guide interventions based on duration of corticosteroid exposure or corticosteroid dose.
Patients taking supraphysiologic doses of glucocorticoids may have increased susceptibility to COVID-19 infection because of the immunosuppressive effects of steroids, comorbidities of underlying immune disorders, or immunomodulatory actions of other therapies in association with glucocorticoids. “The intent here is to ensure that no patient with a history of prior exposure to chronic glucocorticoid therapy (>3 months) by whatever route should die without consideration for parenteral glucocorticoid therapy,” the authors wrote.
Patients with pituitary or other neuroendocrine diseases, including patients with primary adrenal insufficiency with hypopituitarism and secondary adrenal insufficiency, should be closely monitored. These patients may also have diabetes insipidus and should be monitored for fluid and electrolyte replacement to prevent hyponatremia or hypernatremia.
Although the Centers for Disease Control and Prevention (CDC) recommendations for prevention of COVID-19 infection in patients with diabetes mellitus is no different than recommendations for the general population, there is a greater risk for severity of illness with diabetes mellitus. As such, healthcare providers should be vigilant for concerning symptoms such as shortness of breath or fever in these patients.
Of clinical importance, the authors mentioned a possible endocrine-connected clarification of the mechanism of entry of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) into cells. Angiotensin converting enzyme 2 (ACE2) has been established as a SARS-CoV-2 receptor with conflicting data regarding its translational relevance. Therefore, ACE inhibitors/angiotensin receptor blockers may increase susceptibility to COVID-19 infection through upregulation of ACE2, possibly explaining the greater number of hypertensive patients among those who have died from COVID-19 infection. The commentary authors noted that “it is important to stress that these are preliminary reports and should not result in changing prescribed medications at this stage.”
Use of APN01, a recombinant human ACE2, for acute lung injury, acute respiratory distress syndrome, and pulmonary hypertension is being investigated in clinical trials for its ability to slow viral entry into cells and control viral spread. Angiotensin II with angiotension receptor 1 blockers may also reduce mortality from acute respiratory distress syndrome in COVID-19 infection.
In addition, camostat mesylate, a transmembrane protease serine 2 inhibitor, has shown promise against SARS-CoV-2. In Japan, camostat mesylate has been approved for the treatment of pancreatic inflammation. When tested on SARS-CoV-2 isolated from a patient, camostat mesylate prevented the entry of the virus into lung cells.
“Endocrine-related targets are at the forefront of discovery science as we collectively tackle this pandemic,” the authors concluded.
Kaiser UB, Mirmira RG, Stewart PM. Our response to COVID-19 as endocrinologists and diabetologists. J Clin Endocr Metab. 2020;105(5):dgaa148.