Monday February 6, 2006
Tight glycemic control - where we are ?
This week New England Journal of Medicine has published the second part of Dr. Van den Berghe's Intensive Insulin Therapy. This study was done on 1200 patients in medical ICU. As you may remember, her first study of 1548 patients was done in surgical unit and had shown decrease in morbidity as well as mortality. Her present study from medical ICU, though showed significant reduction in morbidity but failed to show any decrease in mortality. But most surprising part of the study, was the analysis of the subset of patients who stayed in the ICU for less than three days. Mortality was actually greater among those patients with intensive insulin therapy. We don't know yet as this data is reproducible or there are other explanations for this result such as early limitations or withdrawals of care. Also to remember, VISEP study from germany which was designed to randomize 600 subjects with medical or surgical severe sepsis to conventional or intensive insulin therapy, was stopped after recruitment of 488 subjects because of no difference in mortality and frequent hypoglycemia in the intensive insulin therapy arm.
What should we do till reults of other major studies like GLUControl (3000 patients) or NICE - SUGAR (5000 patients) are pending. Here are couple of good advises.
1) As Dr. Atul Malhotra wrote in editorial of same issue of NEJM - "In my opinion, a reasonable approach would be to provide adequate exogenous insulin to achieve target glucose values of less than 150 mg per deciliter (8.3 mmol per liter), at least during the first three days in the ICU. If critical illness persists beyond three days despite the provision of other proven therapies and resuscitation, a goal of normoglycemia (80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]) could then be considered, to maximize the potential benefits". OR
2). Dr. Angus and Abraham suggested last year: "..it may be valuable to remember that, although the evidence for tight glycemic control does not yet support a grade A recommendation, it does appear to be stronger than that for continuing our existing practice of tolerating hyperglycemia. Thus, we should probably explore ways to introduce some form of tight glucose control during this interim period that seems feasible and safe given local considerations. Once better evidence is available, we can modify our plans accordingly."
References: Click to get article/abstract: (appears in popup window and second popup overwrites first popup).
1. Intensive Insulin Therapy in the Medical ICU - NEJM, Feb. 2, 2006, Volume 354:449-461
2. Intensive Insulin Therapy in Critically Ill Patients - N Engl J Med 2001; 345:1359-1367, Nov 8, 2001
3.Intensive insulin therapy in patient with severe sepsis and septic shock is associated with an increased rate of hypoglycemia - results from a randomized multicenter study (VISEP), Infection 2005;33: 19-20.
4. Glucontrol Study: Comparing the Effects of Two Glucose Control Regimens by Insulin in Intensive Care Unit Patients -clinicaltrials.gov
5. Normoglycaemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation (NICE - SUGAR STUDY) - clinicaltrials.gov
6. Intensive Insulin in Intensive Care - Volume 354:516-518, NEJM, feb. 2, 2006
7. Intensive Insulin Therapy in Critical Illness, Angus and Abraham Am. J. Respir. Crit. Care Med..2005; 172: 1358-1359
