CME INDIA Presentation by Dr Ambrish Mithal, Chairman & Head, Endocrinology and Diabetes, Max Healthcare D.M.(Endocrinology) – AIIMS, New Delhi – 1987 (First DM in Endocrinology from AIIMS); Awardee – President of India – Padma Bhushan, 2015, Medical Council of India –  B.C. Roy Award, 2015, International Osteoporosis Foundation – President’s Award 2016.

1. Telehealth is the manta: Postpone elective endocrine clinic visits; encourage alternative communication means such as telehealth.

2. Advice to patients: Mail prescriptions, wherever feasible, rather than in-person pickup.

3. Vaccination Update needed: Advise patients to stay updated with recommended vaccinations.

4. Smoking Matters in COVID mortality: Advise patients to avoid smoking.

5. Is COVID related to hypopituitarism: SARS CoV-1 causes long term hypopituitarism, not yet seen in SARS CoV-2.

Cigarette smoking in COVID
Smoking complicates situation in COVID

6. Anosmia and Ageusia pointer to COVID: SARS CoV-2 enters the brain via ACE2 receptor in the olfactory bulb. It causes anosmia and ageusia and the likely etiology is inflamed sensory epithelium, although this is not yet proven.

7. Dehydration (electrolyte and water imbalance) is a key feature of patients with known pituitary conditions and COVID-19: Reasons for this include high fever and tachypnea, diarrhea/vomiting, inability to take adequate fluids (seriously ill patients). Some amount of hypokalemia is also seen due to upregulation of RAAS by degradation of ACE2 receptor by the virus.

8. Avoid hyponatremia in DI: In patients with diabetes insipidus (DI), hyponatremia must be avoided. Allow excessive urination to start and then give the next dose of desmopressin (in older patients). Change route of administration (oral pills rather than nasal desmopressin). In severe COVID, use parenteral desmopressin.

9. Adipsic DI, hypernatremia likely: There is greater tendency towards hypernatremia and thrombosis in adipsic DI. (Adipsic Diabetes Insipidus is a rare hypothalamic disorder characterized by a loss of thirst in response to hypernatremia accompanied by diabetes insipidus. These occur secondary to a congregation of defects in the homeostatic mechanisms of water balance).

10. Fluid Watch: In patients with hypovolemic shock, restore blood volume with 0.9% saline even if hypernatremia. If there is no hypovolemic shock, treat with hypotonic fluids.

Dehydration in COVID
Patients with pituitary conditions will experience dehydration

11. Compromise and accept mild hypernatremia: This is to prevent pulmonary oedema.

12. In patients with pre-existing hyperprolactinemia and severe COVID-19: Consider temporary discontinuation of dopamine receptor agonists to prevent additive vasospasm. Continue DRAs during mild to moderate COVID-19.

13. Do not start on video consultation: If initiating treatment in growth hormone deficient patient, who is COVID positive, call the patient and explain.

14. Adrenals and COVID: SARS-CoV-1 has been demonstrated in adrenal glands, although this has not yet been reported with SARS-CoV-2.

15. Double the steroid dose: In patients with COVID-19 and pre-existing adrenal insufficiency, doubling of steroid dose, as suggested by standard guidelines, might be inadequate due to high levels of acute inflammation. Monitor hospitalised patients for acute adrenal insufficiency and start on IV/IM hydrocortisone.

Steroid dose in COVID
Doubling of Steroid dose might be inadequate

16. Cortisol level and mortality: Evidence has shown association between high serum total cortisol and mortality from COVID-19.

17. Diabetes and hypertension in Cushing syndrome: These have been identified as established poor prognostic factors in COVID-19. Increased fibrinogen, factor VIII and VWF together with impaired fibrinolysis in these patients results in prothrombotic state.

18. Testosterone in COVID19: Low testosterone levels predict adverse outcomes in COVID-19 pneumonia patients. In a study, total testosterone levels were best in Internal Medicine, while lower levels were seen in RICU, ICU and deceased patients.

19. Testicular involvement is common in SARS-CoV-2: “Orchitis-like syndrome.” Keep watch on androgens: Androgens may have a role in COVID-19 severity.

20. Hypogonadism management: Continue the same regimen of hormone replacement for men and women with hypogonadism until they can visit the doctor. Temporary discontinuation has no major hazards.

Testosterone in COIVD
Low testosterone levels is a bad indicator

21. Low TSH and total T3 is seen in COVID-19: After recovery, there are no differences in TSH, TT3, TT4, FT3 and FT4. Degree of decrease in TSH and TT3 has a positive correlation with disease severity.

22. Thyroid histopathological study: It has shown lymphocytic infiltration in the interstitium in SARS-CoV-2, whereas no inflammatory infiltrate and features of cellular necrosis in SARS-CoV-1.

23. Subacute thyroiditis: It has been reported after SARS-CoV-2 infection from Italy. Likely to occur, keeping it in mind needed.

24. TSH receptor antibody can obviate the need for a radioiodine or technetium study: If positive, Graves’s disease; if negative, thyroiditis.

25. Parathyroid and COVID: Patients with chronic renal dysfunction and parathyroid dysfunction may be at risk of COVID-19 due to underlying renal disease.

Bone mineral metabolism disorder and COVID
No evidence of increased risk of COVID-19 in patients with bone-mineral metabolism disorders

26. Hypocalcaemia: It may have an association with COVID-19 severity.

27. In pre-existing parathyroid disorders: Elective surgery like parathyroidectomy can be deferred. Check calcium levels, as HCQ and azithromycin can cause QT prolongation.

28. Correct vitamin D deficiency: These patients are more to develop viral acute respiratory infection. Low dose (1500-2000 units/day), so that patients are at least not below 10ng.

29. Bone mineral metabolism disorders: There is no evidence of increased risk of COVID-19 in patients with bone-mineral metabolism disorders.

30. In patients on IV denosumab: The dose cannot be delayed by more than a couple of weeks. Switch to oral bisphosphonate (alendronate), if cannot get injection. It is recommended that these drugs should not be started among newly diagnosed patients during this pandemic.

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