CMAAO Coronavirus Facts and Myth Buster: Endocrinology : Dr KK Aggarwal

Participants: Dr KK Aggarwal, President CMAAO; Dr RV Asokan, Hony Secretary General IMA; Dr Ramesh K Datta, Hony Finance Secretary IMA; Dr Avtar Krishna; Dr S Sharma

Faculty: Dr Ambrish Mithal, Chairman & Head, Endocrinology and Diabetes, Max Healthcare

• Postpone elective endocrine clinic visits; encourage alternative communication means such as telehealth.
• Mail prescriptions, wherever feasible, rather than in-person pickup.
• Advice patients to stay updated with recommended vaccinations.
• Advice patients to avoid smoking.
• SARS CoV-1 causes long-term hypopituitarism, not yet seen in SARS CoV-2.
• SARS CoV-2 enters the brain via ACE2 receptors in the olfactory bulb. It causes anosmia and ageusia and the likely etiology is inflamed sensory epithelium, although this is not yet proven.
• 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.
• 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.
• There is greater tendency towards hypernatremia and thrombosis in adipsic DI.
• 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.
• Compromise and accept mild hypernatremia to prevent pulmonary edema.
• 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.
• If initiating treatment in growth hormone deficient patient, who is COVID positive, call the patient and explain. Do not start on video consultation.
• SARS-CoV-1 has been demonstrated in adrenal glands, although this has not yet been reported with SARS-CoV-2.
• 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 hospitalized patients for acute adrenal insufficiency and start on IV/IM hydrocortisone.
• Evidence has shown an association between high serum total cortisol and mortality from COVID-19.
• Diabetes and hypertension in Cushing syndrome 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.
• 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.
• Testicular involvement is common in SARS-CoV-2 “orchitis-like syndrome”.
• Androgens may have a role in COVID-19 severity.
• 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.
• 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.
• Thyroid histopathological study has shown lymphocytic infiltration in the interstitium in SARS-CoV-2, whereas no inflammatory infiltrate and features of cellular necrosis in SARS-CoV-1.
• Subacute thyroiditis has been reported after SARS-CoV-2 infection from Italy.
• TSH receptor antibody can obviate the need for a radioiodine or technetium study. If positive, Graves’s disease; if negative, thyroiditis.
• Patients with chronic renal dysfunction and parathyroid dysfunction may be at risk of COVID-19 due to underlying renal disease.
• Hypocalcemia may have an association with COVID-19 severity.
• In pre-existing parathyroid disorders, elective surgery like parathyroidectomy can be deferred. Check calcium levels, as HCQ and azithromycin can cause QT prolongation.
• Correct vitamin D deficiency as such patients are more likely to develop viral acute respiratory infection. Low dose (1500-2000 units/day), so that patients are at least not below 10ng.
• There is no evidence of increased risk of COVID-19 in patients with bone-mineral metabolism disorders.
• 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.

Author : Dr KK Aggarwal , President CMAAO, HCFI and Past National President IMA