Tight control of BG in the ICU may be dangerous: the NICE-SUGAR study   (March 25, 2009)

Another cute acronym, NICE-SUGAR, is the acronym for "Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation," a study that was just published in the New England Journal of Medicine. The authors looked at intensive versus conventional glucose control in critically ill patients in intensive care units (ICUs).

The conclusion of the study is a bit of a surprise, and is the second study in just over a year that has concluded that intensive glucose therapy may be deleterious to patient health. (The other one was ACCORD, which I have written about several times previously.) The researchers from NICE-SUGAR concluded that intensive glucose control increased mortality among adults in the ICU: a "conventional-control" blood glucose target of 180 mg/dl (or less) resulted in lower mortality than did an "intensive-control" target of 81 to 108 mg/dl.

They looked at 6104 patients; 3054 were assigned to undergo intensive control and 3050 to undergo conventional control; they found that 829 patients (27.5%) in the intensive-control group and 751 (24.9%) in the conventional-control group died. Results were similar for surgical patients as for medical patients. Unsurprisingly, severe hypoglycemia was more common in intensively-treated patients (in 6.8%) compared to conventionally-treated patients (0.5%). Number of days in the ICU, number of days on mechanical ventilation, and days on dialysis were not different.

Sounds convincing: tight control of glucose in the ICU is not helpful, but is actually harmful.

The study caused an immediate response from two major organizations: The American Diabetes Association and the American Association of Clinical Endocrinologists put out a joint statement, Response to March 24 article in the New England Journal of Medicine. In it, they point out that the severely ill patients in NICE-SUGAR were treated intensively with intravenous insulin to very tight targets (average of 115 mg/dl), and were compared to a control group whose glucose control was really pretty good, all things considered (average glucose 144 mg/dl). They don't dispute these findings of NICE-SUGAR, but advise that this study should not lead to an abandonment of the concept of good glucose management in the hospital setting, as it is well-known that uncontrolled high blood glucose can lead to serious problems for hospitalized patients. They caution, appropriately, against letting this study swing the pendulum of glucose control too far in the other direction to where physicians might become complacent about uncontrolled hyperglycemia in the hospital.

Recognizing the importance of controlling hyperglycemia, the two organizations recently convened a Consensus Panel to extensively review the most current literature and up-to-date recommendations for treatment of hyperglycemia in the hospital. They plan to publish recommendations from their panel later this year.

I agree with the closing comment from ADA/AACE: Until more information is available, it seems reasonable for physicians to treat critical care patients with less intensive - yet good - glucose control strategies, but don't allow BG levels in hospitalized patients to remain uncontrolled.