NICE-SUGAR

Summary by Rich Jordan MD, 12.20.21

Intensive versus conventional glucose control in critically ill patients (NICE-SUGAR) (Finfer et al, 2009)

Design: Multi-center, non-blinded, parallel group RCT.

Intervention: Intensive glucose control of 81 to 108 mg/dL (n = 3054) versus conventional glucose control of less than 180 mg/dL (n = 3050). Intervention discontinued when patients were eating, discharge from the ICU, deceased, or after 90 days from randomization

Results: 97.2% of the intensive group and 69% of the conventional group required insulin during the trial. Intensive group mean glucose =115 mg/dL. Conventional group mean glucose = 144 mg/dL. Statistically significant difference in 90-day mortality 27.5% versus 24.9% (p = 0.02). Statistically significant difference in incidence of severe hypoglycemia (defined as glucose less than or equal to 40 mg/dL) 6.8% versus 0.5% (p <0.001). No difference in mortality rate at 28 days, medium length of ICU/hospital stay, development of new organ failure, number of days of mechanical ventilation, renal replacement therapy, rates of red cell transfusion, and positive blood cultures.

Conclusions: Blood glucose targets of less than 180 mg/dL resulted in lower mortality compared to targets of 81 to 108 mg/dL in critically ill patients.

Additional evidence:

Below is another RCT (n=400) from 2007 (Annals of Internal Medicine) in a tertiary care center (single center) in Minnesota, that addressed the same question - but in cardiac surgery patients.

Findings:

- No mortality benefit in intensive glycemic control (target glucose <100).

- Increased risk of strokes in the intensive glycemic control group.

- No difference in mortality, sternal infection, cardiac arrest, heart block requiring PM, A.fib, renal failure, or prolonged intubation.

Conclusions:

--> Intensive insulin therapy during cardiac surgery does not reduce perioperative death or morbidity.

Reference: Gandhi GY, Nuttall GA, Abel MD, Mullany CJ, Schaff HV, O'Brien PC, Johnson MG, Williams AR, Cutshall SM, Mundy LM, Rizza RA, McMahon MM. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial. Ann Intern Med. 2007 Feb 20;146(4):233-43. doi: 10.7326/0003-4819-146-4-200702200-00002. PMID: 17310047.