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Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data.
CMAJ. 2009 Apr 14; 180(8):821-7.CMAJ

Abstract

BACKGROUND

Hyperglycemia is associated with increased mortality in critically ill patients. Randomized trials of intensive insulin therapy have reported inconsistent effects on mortality and increased rates of severe hypoglycemia. We conducted a meta-analysis to update the totality of evidence regarding the influence of intensive insulin therapy compared with conventional insulin therapy on mortality and severe hypoglycemia in the intensive care unit (ICU).

METHODS

We conducted searches of electronic databases, abstracts from scientific conferences and bibliographies of relevant articles. We included published randomized controlled trials conducted in the ICU that directly compared intensive insulin therapy with conventional glucose management and that documented mortality. We included in our meta-analysis the data from the recent NICE-SUGAR (Normoglycemia in Intensive Care Evaluation - Survival Using Glucose Algorithm Regulation) study.

RESULTS

We included 26 trials involving a total of 13 567 patients in our meta-analysis. Among the 26 trials that reported mortality, the pooled relative risk (RR) of death with intensive insulin therapy compared with conventional therapy was 0.93 (95% confidence interval [CI] 0.83-1.04). Among the 14 trials that reported hypoglycemia, the pooled RR with intensive insulin therapy was 6.0 (95% CI 4.5-8.0). The ICU setting was a contributing factor, with patients in surgical ICUs appearing to benefit from intensive insulin therapy (RR 0.63, 95% CI 0.44-0.91); patients in the other ICU settings did not (medical ICU: RR 1.0, 95% CI 0.78-1.28; mixed ICU: RR 0.99, 95% CI 0.86-1.12). The different targets of intensive insulin therapy (glucose level < or = 6.1 mmol/L v. < or = 8.3 mmol/L) did not influence either mortality or risk of hypoglycemia.

INTERPRETATION

Intensive insulin therapy significantly increased the risk of hypoglycemia and conferred no overall mortality benefit among critically ill patients. However, this therapy may be beneficial to patients admitted to a surgical ICU.

Authors+Show Affiliations

Department of Medicine, University of British Columbia, Vancouver, Canada.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Meta-Analysis
Review

Language

eng

PubMed ID

19318387

Citation

Griesdale, Donald E G., et al. "Intensive Insulin Therapy and Mortality Among Critically Ill Patients: a Meta-analysis Including NICE-SUGAR Study Data." CMAJ : Canadian Medical Association Journal = Journal De l'Association Medicale Canadienne, vol. 180, no. 8, 2009, pp. 821-7.
Griesdale DE, de Souza RJ, van Dam RM, et al. Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. CMAJ. 2009;180(8):821-7.
Griesdale, D. E., de Souza, R. J., van Dam, R. M., Heyland, D. K., Cook, D. J., Malhotra, A., Dhaliwal, R., Henderson, W. R., Chittock, D. R., Finfer, S., & Talmor, D. (2009). Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. CMAJ : Canadian Medical Association Journal = Journal De l'Association Medicale Canadienne, 180(8), 821-7. https://doi.org/10.1503/cmaj.090206
Griesdale DE, et al. Intensive Insulin Therapy and Mortality Among Critically Ill Patients: a Meta-analysis Including NICE-SUGAR Study Data. CMAJ. 2009 Apr 14;180(8):821-7. PubMed PMID: 19318387.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. AU - Griesdale,Donald E G, AU - de Souza,Russell J, AU - van Dam,Rob M, AU - Heyland,Daren K, AU - Cook,Deborah J, AU - Malhotra,Atul, AU - Dhaliwal,Rupinder, AU - Henderson,William R, AU - Chittock,Dean R, AU - Finfer,Simon, AU - Talmor,Daniel, Y1 - 2009/03/24/ PY - 2009/3/26/entrez PY - 2009/3/26/pubmed PY - 2009/5/5/medline SP - 821 EP - 7 JF - CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne JO - CMAJ VL - 180 IS - 8 N2 - BACKGROUND: Hyperglycemia is associated with increased mortality in critically ill patients. Randomized trials of intensive insulin therapy have reported inconsistent effects on mortality and increased rates of severe hypoglycemia. We conducted a meta-analysis to update the totality of evidence regarding the influence of intensive insulin therapy compared with conventional insulin therapy on mortality and severe hypoglycemia in the intensive care unit (ICU). METHODS: We conducted searches of electronic databases, abstracts from scientific conferences and bibliographies of relevant articles. We included published randomized controlled trials conducted in the ICU that directly compared intensive insulin therapy with conventional glucose management and that documented mortality. We included in our meta-analysis the data from the recent NICE-SUGAR (Normoglycemia in Intensive Care Evaluation - Survival Using Glucose Algorithm Regulation) study. RESULTS: We included 26 trials involving a total of 13 567 patients in our meta-analysis. Among the 26 trials that reported mortality, the pooled relative risk (RR) of death with intensive insulin therapy compared with conventional therapy was 0.93 (95% confidence interval [CI] 0.83-1.04). Among the 14 trials that reported hypoglycemia, the pooled RR with intensive insulin therapy was 6.0 (95% CI 4.5-8.0). The ICU setting was a contributing factor, with patients in surgical ICUs appearing to benefit from intensive insulin therapy (RR 0.63, 95% CI 0.44-0.91); patients in the other ICU settings did not (medical ICU: RR 1.0, 95% CI 0.78-1.28; mixed ICU: RR 0.99, 95% CI 0.86-1.12). The different targets of intensive insulin therapy (glucose level < or = 6.1 mmol/L v. < or = 8.3 mmol/L) did not influence either mortality or risk of hypoglycemia. INTERPRETATION: Intensive insulin therapy significantly increased the risk of hypoglycemia and conferred no overall mortality benefit among critically ill patients. However, this therapy may be beneficial to patients admitted to a surgical ICU. SN - 1488-2329 UR - https://www.unboundmedicine.com/medline/citation/19318387/Intensive_insulin_therapy_and_mortality_among_critically_ill_patients:_a_meta_analysis_including_NICE_SUGAR_study_data_ L2 - http://www.cmaj.ca/cgi/pmidlookup?view=long&amp;pmid=19318387 DB - PRIME DP - Unbound Medicine ER -