Intensive insulin therapy has its own risks

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Intensive insulin treatment increases significantly the risk of hypoglycemia in critically ill patients, found a newly released study in CMAJ (http://www.cmaj.ca/press/cmaj.090206.pdf).

Intensive insulin treatment is used in a number of intensive care units around the world as a means to tightly regulate blood sugar. Eventhough labour intensive, it has been recommended as a standard of care for critically ill patients by a number of organizations including the American Diabetes Association and the American Association of Clinical Endocrinologists.

A randomized trial in 2001 reported that intensive insulin treatment significantly reduced hospital mortality, eventhough subsequent trials have reported inconsistent effects on mortality and higher rates of severe hypoglycemia.

The CMAJ study includes data from 26 trials, including the NICE-SUGAR Study on intensive insulin treatment, an international, multicentre randomized trial that is the largest intensive insulin treatment trial to date. The NICE-SUGAR study is published online in the New England Journal (NEJM) March 24, 2009 and March 26 for the print edition.

"By including the largest trial on intensive insulin treatment published to date, we provide the most current and precise estimate of the effect of intensive insulin treatment on vital status and hypoglycemia in the ICU setting," write Dr. Donald Griesdale, anesthesiologist and critical care doctor at Vancouver General Hospital and clinical instructor at the University of British Columbia, and coauthors.

The CMAJ study looked at 26 trials involving 13 567 patients. There was a 6-fold increased risk of hypoglycemia in comparison to the control therapy.

The study was conducted by scientists from the University of British Columbia and Vancouver General Hospital, Vancouver, BC; Harvard School of Public Health, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Boston, Mass; Queen's University and Kingston General Hospital, Kingston, Ontario; McMaster University, Hamilton, Ontario; Royal North Shore Hospital and the University of Sydney, Australia.

"We suggest that policy makers reconsider recommendations promoting the use of intensive insulin treatment in all critically ill patients," write the authors. However, because the study included data from trials in different populations with varied illness severity, they "cannot exclude the possibility that some patients appears to benefit from intensive insulin treatment and be at less risk of hypoglycemic events".

In a related commentary (http://www.cmaj.ca/press/cmaj.090500.pdf), Dr. Greet Van den Berghe and his colleagues argue that differences in specific elements of how intensive insulin treatment was delivered account for the varying findings of individual studies and that a single guideline for intensive insulin treatment applicable to all patients is not appropriate.


Posted by: JoAnn    Source