Colombo, Sri Lanka—Medication adjustments might be necessary in patients with pre-existing endocrine disorders who develop COVID-19.

That’s according to a new review published in the Journal of the Endocrine Society.

“We explored the previous SARS outbreak caused by the very similar virus SARS-CoV-1 to advise endocrinologists involved in the care of patients with COVID-19,” said Noel Pratheepan Somasundaram of the National Hospital of Sri Lanka in Colombo, Sri Lanka. “The virus that causes COVID-19--SARS-CoV-2--binds to the ACE2 receptor, a protein which is expressed in many tissues. This allows the virus to enter endocrine cells and cause the mayhem associated with the disease.”

The authors make several points about management decisions of patients with endocrine disorders, including:
• Hydrocortisone dose adjustments are required in patients with adrenal insufficiency.
• Identification and management of corticosteroid insufficiency related to critical illness is crucial.
• Patients with Cushing’s syndrome may have poorer outcomes due to the associated immunodeficiency and coagulopathy.
• Vitamin D deficiency appears to be associated with increased susceptibility or severity to SARS-CoV-2 infection, and replacement might improve outcomes.

“People with vitamin D deficiency may be more susceptible to coronavirus and supplementation could improve outcomes, though evidence on the subject is mixed,” Somasundaram said.

The authors also advise that COVID-19 could lead to new cases of diabetes and worsening of existing diabetes. They point out that the SARS-CoV-2 virus attaches to ACE2, the main entry point into cells for coronavirus, and disrupts insulin production, causing high blood glucose levels in some patients. The result is the need for strict glucose monitoring in patients with COVID-19.

To reach those conclusions, researchers performed a literature survey using the key words COVID-19, Coronavirus, SARS CoV-1, SARS Cov-2, endocrine, and related terms in medical databases including PubMed, Google Scholar, and MedARXiv from 2000. Additional references were identified through manual screening of bibliographies and via citations in the selected articles. The literature review is current until April 28, 2020.

The review explains how SARS-CoV-2 can cause loss of smell and gain entry to the brain. The authors recount how, in past coronavirus infections such as the SARS epidemic in 2003, many patients developed a postviral syndrome with fatigue. They suggest that one reason could be adrenal insufficiency, a condition where the adrenal glands do not make enough cortisol as a result of damage to the pituitary system. During the SARS epidemic, patients who developed adrenal insufficiency typically recovered within 1 year, they add.

“Testing for cortisol deficiency and treating patients with steroids may become a vital treatment strategy,” Dr. Somasundaram said. “Very recent studies have demonstrated lowered mortality in severely-ill patients with COVID-19 treated with the steroid dexamethasone.”

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