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Why is diabetes a risk factor for coronavirus disease 2019 (COVID-19)?

High plasma glucose levels and diabetes mellitus (DM) are known risk factors for pneumonia.
Potential mechanisms that may increase the susceptibility for COVID-19 in patients with DM include the following:
1. Higher-affinity cellular binding and efficient virus entry.
2. Decreased viral clearance.
3. Diminished T-cell function.
4. Increased susceptibility to hyperinflammation and cytokine storm syndrome.
5. Presence of cardiovascular disease.
SARS-CoV-2 is known to utilize angiotensin-converting enzyme 2 (ACE2) receptors for entry into target cells.
Insulin administration attenuates (to make something weaker, smaller or less effective) ACE2 expression, while hypoglycemic agents (eg, glucagonlike peptide 1 [GLP-1] agonists, thiazolidinediones) up-regulate ACE2.
Dipeptidyl peptidase 4 (DPP-4) is highly involved in glucose and insulin metabolism, as well as in immune regulation. This protein was shown to be a functional receptor for Middle East respiratory syndrome coronavirus (MERS-CoV), and protein modeling suggests that it may play a similar role with SARS-CoV-2, the virus responsible for COVID-19.
Dipeptidyl peptidase-4 inhibitors (gliptins) E.g., Sitagliptin, Saxagliptin, Linagliptin
These indirectly increase the endogenous incretin effect by inhibiting the DPP-4 that breaks down GLP-1 → ↑ insulin secretion, ↓ glucagon secretion, delayed gastric emptying.
incretin is digestive tract hormone that increases insulin secretion from beta cells of the pancreas, decreases glucagon levels and slows gastric emptying in response to food intake. Two major incretins are glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP).
The relationship between diabetes, coronavirus infections, ACE2, and DPP-4 has been reviewed by Drucker. Important clinical conclusions of the review include the following:
• Hospitalization is more common for acute COVID-19 among patients with diabetes and obesity.
• Diabetic medications need to be reevaluated upon admission for every patient who is suffering from diabetes
• Insulin is the glucose-lowering therapy of choice, not DPP-4 inhibitors or GLP-1 receptor agonists, in patients with diabetes who are hospitalized with acute COVID-19.

Sources
1.https://www.ncbi.nlm.nih.gov/pmc/arti...
2.https://www.ncbi.nlm.nih.gov/pmc/arti...
3.https://www.researchgate.net/post/Why...
4.https://journals.plos.org/plosone/art...
5.https://www.touchendocrinology.com/in...
6.https://www.thelancet.com/journals/la...

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