Latest research, recommendations cover diabetes, clots, and remdesivir in COVID-19

Mortality was lower in diabetes patients given sitagliptin at admission for COVID-19, ACP practice points support remdesivir, acquired thrombophilia does not predict clots, cardiac arrest survival is low, and admissions for other conditions were still way down over the summer.

Sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor, was associated with lower mortality in patients hospitalized with COVID-19, according to an Italian study published by Diabetes Care on Sept. 29. The retrospective, observational, case-control study included 169 patients with type 2 diabetes who were given sitagliptin (in addition to usual care, including insulin) starting at admission for COVID-19, matched to an equal number of controls receiving usual care. All patients had pneumonia and oxygen saturation below 95%. Treatment with sitagliptin was associated with reduced risk of mortality (18% vs. 37%; P=0.0001) and higher likelihood of improvement in clinical score (60% vs. 38%; P=0.0001) at 30 days. The authors noted that there are multiple biological explanations for why DPP-4 inhibitors may be beneficial in treatment of COVID-19 and called for confirmation of their results with randomized, controlled trials of sitagliptin.

The use of remedsivir for COVID-19 was supported by new living practice points from ACP. The practice points, published by Annals of Internal Medicine on Oct. 5 and based on a rapid systematic review of best available evidence, find that the evidence indicates a net benefit from remdesivir in COVID-19. They recommend five days of therapy in patients with moderate COVID-19 or severe COVID-19 not requiring mechanical ventilation or extracorporeal membrane oxygenation (ECMO). Clinicians should consider extending the use of remdesivir to 10 days in patients with severe COVID-19 requiring mechanical ventilation or ECMO within a five-day course. The practice points also say it is reasonable to consider extending treatment to 10 days for patients whose condition does not improve during the initial five days.”

Indicators of acquired thrombophilia do not necessarily predict thrombotic events in patients with COVID-19, according to a study published by the Journal of the American Heart Association on Sept. 25. The analysis of 89 consecutive patients hospitalized for COVID-19 in France found a 20% prevalence of protein S deficiency and a 72% prevalence of antiphospholipid antibodies, mainly lupus anticoagulant. However, the presence of these abnormalities was not associated with prolonged activated partial thromboplastin time or D-dimer, fibrinogen, or C-reactive protein concentrations. The authors concluded that these markers do not seem to explain thrombosis in COVID-19 patients and are not correlated to disease severity or prognosis. They added that “the presence of frequent acquired thrombophilia may be part of the inflammation storm of Covid-19 disease and should not systematically modify our strategy on prophylactic anticoagulant treatment which is already revised upwards in this pathology.”

A new study of in-hospital cardiac arrest in patients with COVID-19 found low rates of survival, but not as low as those in research covered in last week's issue. The study of 5,019 critically ill patients hospitalized in the U.S. with COVID-19 found that 14.0% had in-hospital cardiac arrest, according to results published by The BMJ on Sept. 30. Of the 400 patients (57.1%) who received CPR, 48 (12.0%) survived to hospital discharge, including 28 (7.0%) who had normal or mildly impaired neurological status. The authors concluded that cardiac arrest is common in critically ill patients with COVID-19 and associated with poor survival, particularly among older patients. The results “should prompt clinicians to design systems that are able to accommodate for large numbers of these events during future outbreaks, including methods to protect frontline healthcare providers from infection,” and could also be used to guide end-of-life care discussions, the authors said.

Finally, a study published by Health Affairs on Sept. 24 looked at how hospital admissions for other conditions were affected as the COVID-19 pandemic wore on, using data from a large hospitalist group (Sound Physicians). After an across-the-board drop of more than 20% in February through April, admissions for conditions other than COVID-19 had rebounded to 16% below their usual volume. However, there were more significant ongoing decreases among patients living in majority-Hispanic neighborhoods and those who were self-paying, as well as for certain conditions: pneumonia (−44%), COPD/asthma (−40%), sepsis (−25%), urinary tract infection (−24%), and acute ST-elevation myocardial infarction (−22%). “Our results provide empirical support for concerns about the broad public health impact of the pandemic on non-COVID-19 populations. Some medical conditions (e.g., stroke, STEMI) require effective hospital treatment to avoid adverse outcomes; therefore fewer hospitalizations for such medical conditions are almost certainly associated with patient harm,” the authors said. Other recent research on the effects of the pandemic on Americans' health found a rise in alcohol use and internet searches about anxiety, panic attacks, and insomnia.