Tuesday, March 24, 2009

Tight glucose control in ICU seems hazardous

In the March 24,2009 on line issue of NEJM the results of the Nice Sugar trial are published and shows that conventional treatment ( target glucose less than 180) as opposed to tight control (defined as 81-108 glucose target) is better. This was a very large trial with over 3000 patients in each arm.

In the tight control group 27.5 % died versus 24.9 % deaths in the conventional treatment group.Severe hypoglycemia (less than 40) occurred in 6. 5 % of the intensive treatment group versus 0.5 % in the conventional treatment group illustrating once more that more insulin may drive the blood sugar too low and be harmful.

Even though meta-analysis have generated conflicting results regarding the efficacy and safety of tight glucose control, both the American Diabetes Association and the American Society of Clinical Endocrinologists have recommended tight control.

The study authors of the NICE trial offered this understatement "Our findings suggest that a goal of normoglycemia for glucose control does not necessarily benefit critically ill patients and may be harmful",

This seems to be another example of the ready, shoot, aim approach to guidelines bringing to mind the ill advised rush to give everyone beta blockers peri-operatively which was probably laid to rest with the publication of the POISE Trial. Let me repeat what I said after that trial was published.

If there is a lesson here it is not just that a large randomized clinical trial gives results opposite to earlier smaller trials-that is a story we have heard more than once before. The lesson is not that expert committees sometimes have to revise their recommendations as new information becomes available.The lesson I think that should be emphasized is that overzealous quality rule writers and enforcers can be a hazard to your health ( and I have said that before). Read Dr. Devereaux's comments regarding how many patients may have been harmed by taking peri operative beta blockers and then wonder how many patients received them simply because premature quality guidelines were in place and physicians were caught up in the rush to treat even though it seems clear now that the evidence for such zealous efforts was inadequate. Dr. DB (AKA Dr. Robert Centor) nailed it when he recently spoke about in this regard " the performance and quality movement which has a 'ready,fire, aim' philosophy".

No comments: