NICE-SUGAR is out

[proman]

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The eagerly awaited NICE-SUGAR study is out (epub NEJM)Background The optimal target range for blood glucose in critically ill patients remains unclear.

Methods Within 24 hours after admission to an intensive care unit (ICU), adults who were expected to require treatment in the ICU on 3 or more consecutive days were randomly assigned to undergo either intensive glucose control, with a target blood glucose range of 81 to 108 mg per deciliter (4.5 to 6.0 mmol per liter), or conventional glucose control, with a target of 180 mg or less per deciliter (10.0 mmol or less per liter). We defined the primary end point as death from any cause within 90 days after randomization.

Results Of the 6104 patients who underwent randomization, 3054 were assigned to undergo intensive control and 3050 to undergo conventional control; data with regard to the primary outcome at day 90 were available for 3010 and 3012 patients, respectively. The two groups had similar characteristics at baseline. A total of 829 patients (27.5%) in the intensive-control group and 751 (24.9%) in the conventional-control group died (odds ratio for intensive control, 1.14; 95% confidence interval, 1.02 to 1.28; P=0.02). The treatment effect did not differ significantly between operative (surgical) patients and nonoperative (medical) patients (odds ratio for death in the intensive-control group, 1.31 and 1.07, respectively; P=0.10). Severe hypoglycemia (blood glucose level, 40 mg per deciliter [2.2 mmol per liter]) was reported in 206 of 3016 patients (6.8%) in the intensive-control group and 15 of 3014 (0.5%) in the conventional-control group (P<0.001). There was no significant difference between the two treatment groups in the median number of days in the ICU (P=0.84) or hospital (P=0.86) or the median number of days of mechanical ventilation (P=0.56) or renal-replacement therapy (P=0.39).

Conclusions In this large, international, randomized trial, we found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 180 mg or less per deciliter resulted in lower mortality than did a target of 81 to 108 mg per deciliter.

Will this change anyone's practice? Should intensive insulin therapy be used in anyone other than the post-cardiac surgery patient?

 

[Hernandez]

Will this change anyone's practice? Should intensive insulin therapy be used in anyone other than the post-cardiac surgery patient?

No, I've been using a moderate stratergy to maintain less than 100-180 range while I've been waiting for this trial to come out. It's about time they got it done. I'm only halfway through reading the whole article though.

 

[southerndoc]

Will this change anyone's practice? Should intensive insulin therapy be used in anyone other than the post-cardiac surgery patient?

Our intensivists have never done it since I've been in private practice. Any of the boarders are allowed to be hyperglycemic up to 180. Not sure if they were privy to some of the research before it came out.

During residency we had strict hyperglycemia protocols, but not sure if that changed at the end of my residency since my last ICU rotation was in my third year of residency.

Where do they come up with names of these studies? NICE-SUGAR? I have to admit, I have seen worse names.

 

[JayneCobb]

It's really interesting that the median ICU stay was what 4-5 days yet the increased mortality was at 90 days, not 28.

 

[BlackNDecker]

It's really interesting that the median ICU stay was what 4-5 days yet the increased mortality was at 90 days, not 28.

Maybe because it takes that long to see the cumulative effects of insults on multiple organ systems.

The PI came and spoke at Grand Rounds at my institution...a brilliant EBM guru from Australia. He delivered some effective criticism of prior studies showing benefit with tight glycemic control, particularly, that these prior studies were performed at single institutions. NICE-SUGAR was a multi-center, international study.

 

[JayneCobb]

Maybe because it takes that long to see the cumulative effects of insults on multiple organ systems.

The PI came and spoke at Grand Rounds at my institution...a brilliant EBM guru from Australia. He delivered some effective criticism of prior studies showing benefit with tight glycemic control, particularly, that these prior studies were performed at single institutions. NICE-SUGAR was a multi-center, international study.

Possibly, I agree that it seemed like a very well done study and I really can't find fault with the design, the 90 day mortality is the only thing which just stuck out at me as odd without any explination. Anyways, with no benefit at 28 days or any other surrogate marker, I see no reason to emply a tight glycemic control on a MICU pt at this point.