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Intensive Glucose Control Harms Critically Ill Patients

More evidence that just keeping glucose levels <180 mg/dL is better than striving for very low levels.

Prior studies of the effects of intensive glucose control in critically ill patients have yielded conflicting results. Now, in a multicenter trial (NICE-SUGAR), investigators randomized more than 6000 critically ill patients (63% medical; 37% surgical) to either intensive glucose control (target glucose level, 81–108 mg/dL) or conventional glucose control (target glucose level, 144–180 mg/dL). Control of blood glucose was achieved with intravenous insulin infusions. Participants were randomized within 24 hours after admission to intensive care units and were expected to require ICU treatment for 3 or more consecutive days.

The primary endpoint — death by 90 days after randomization — occurred significantly more often in the intensive-control group than in the conventional-control group (27.5% vs. 24.9%). When data were analyzed separately for medical and surgical patients, results were similar to those for the whole cohort. Not surprisingly, severe hypoglycemia (blood glucose level, 40 mg/dL) was significantly more common in the intensive-control group than in the conventional-control group (6.8% vs. 0.5%). No differences between the groups were observed in median number of ICU or hospital days or median days of mechanical ventilation or renal replacement therapy.

Comment: The results of the NICE-SUGAR trial suggest that intensive glucose control harms critically ill patients in terms of death (number needed to harm, 38) and episodes of severe hypoglycemia. As an editorialist notes, the results do not suggest that clinicians revert to "neglectful" means of glucose control, such as insulin sliding scales, in critically ill patients. Instead, clinicians should strive for reasonable control (i.e., glucose levels in the mid-100s) in such patients.

— Paul S. Mueller, MD, MPH, FACP

Published in Journal Watch General Medicine March 24, 2009

Citation(s):

The NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009 Mar 26; 360:1283. (http://dx.doi.org/10.1056/NEJMoa0810625)

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• Medline abstract (Free)

Inzucchi SE and Siegel MD. Glucose control in the ICU — How tight is too tight? N Engl J Med 2009 Mar 26; 360:1346. (http://dx.doi.org/10.1056/NEJMe0901507)

• Original article (Subscription may be required)
• Medline abstract (Free)