Thursday, September 25, 2008

Glycemic control in critical illness: we know even less than we thought we did

Glycemic targets for hospitalized patients seem to be moving targets. I tried to make sense of it all with a review of evidence late last year. At that time evidence was on the negative side for strict glycemic control (110 mg/dl or below). The optimal glycemic target was not known, but many experts thought 150 mg/dl was reasonable. Now comes this meta-analysis in JAMA which would seem to be yet another nail in the coffin of tight glycemic control in hospitalized patients. As other studies had shown, tight glycemic control produced no overall benefit beyond “usual care.” What was new in this study was that a “moderate” glycemic target of 150 mg/dl, the consensus of many experts today, was no better than very tight control or usual care.

So what’s the current status of glycemic control in hospitalized patients?

The optimal target may be somewhere above 150 mg/dl but we don’t know what that threshold is. At some level, glycemic control matters. In the methods section of the meta-analysis it was implied that in some studies usual care glucose may differ from tight control levels by as little as 20 mg/dl. Thus even usual control in some negative clinical trials may be better than what we achieve in the community. The ongoing NICE SUGAR trial, comparing very tight control with a target of 180 mg/dl, may shed further light.

Background:

Accompanying JAMA editorial.

Med Rants weighs in.

Med Page Today has a synopsis and an interview with the lead investigator.

1 comment:

WakingUpCosts said...

Hopefully, accumulating literature such as what you point to will convince over-eager endocrinologists to stop trying to institute tight glycemic control in non-diabetic, non-critically ill surgical patients.