Tuesday, June 09, 2009

After NICE-SUGAR, now what?

NICE-SUGAR, it was hoped, would provide the “final answer” to the question of the appropriate glycemic target in the critically ill patient with hyperglycemia. But its results were disappointing to proponents of intensive glycemic control. What are doctors to do now?

Editorial writers in a recent issue of Mayo Clinic Proceedings summarize the current situation this way:

Despite these caveats, we think it is important to emphasize that the findings of NICE-SUGAR do not justify neglecting glycemic control. Instead, we think that, whatever the mechanisms behind the findings of NICE-SUGAR, there is now a new and more moderate standard of care for glycemic management in the ICU: do not treat hyperglycemia unless the glucose level increases higher than 180 mg/dL; when you do treat hyperglycemia, aim for a target blood glucose concentration between 144 and 180 mg/dL. Until a study can provide level I evidence that a better approach exists, this should remain the standard of care. Such a standard of care also implies that, for example, in patients in the ICU, a glucose level of 243 mg/dL is just as undesirable as a glucose level of 80 mg/dL.

That’s a reasonable statement to guide clinicians but I would have avoided the term “standard of care” which just gives fuel to the trial lawyers. Because we still lack evidence as to what is the best glycemic target for any hospitalized patients, in the ICU or elsewhere, no range of blood sugar can be said to be standard of care.

They go on to say:

Finally, and this is vital, no matter what clinicians think might explain the findings of NICE-SUGAR, they should remember to be wary of the next single-center study that promises a simple solution for a complex problem. Single-center studies simply do not have the ability or resources to provide the type of scientifically rigorous analysis delivered by large multicenter, randomized controlled trials.37-39 Waiting for level I evidence to emerge before adopting a risky therapy is and will remain the best policy in clinical medicine for a long time.

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