Paul G. Wasielewski, MD; Ken Uchino, MD
Does using intravenous (IV) insulin to maintain normoglycemia in the first 24 hours after acute ischemic stroke reduce death or dependency?
Included studies compared insulin with placebo or no treatment, high- with low-dose insulin, or tight with loose glycemic control to maintain a glycemic level between 4 and 7.5 mmol/L (72 to 135 mg/dL) in adults who presented within 24 hours of acute ischemic stroke and had blood glucose levels > 6.1 mmol/L (110 mg/dL). Interventions had to start within 24 hours of symptom onset. Primary outcome was death or dependency (Barthel Index score ≤ 60 or modified Rankin Scale grade 3 to 6) at the end of follow-up. Secondary outcomes included death, hypoglycemia (blood glucose levels < 3 mmol/L [54 mg/dL]), and neurologic deficit (National Institutes of Health Stroke Scale and European Stroke Scale).
MEDLINE, EMBASE/Excerpta Medica, CINAHL, Cochrane Stroke Group Trials Register, Science Citation Index, and Web of Science (all to Jun 2010); Cochrane Central Register of Controlled Trials (Issue 2, 2010); Stroke Trials Directory; ClinicalTrials.gov; Current Controlled Trials; and SCOPUS were searched for randomized controlled trials (RCTs). 7 RCTs (n = 1296, mean age 74 y) met the selection criteria; 5 had adequate allocation concealment, 4 had blinded outcome assessors, and 1 had blinded patients.
Meta-analysis showed that IV insulin to maintain normoglycemia did not differ from loose control for death or dependency; risk for hypoglycemia was higher in the intervention group (Table). Groups did not differ for neurologic deficits (standardized mean difference −0.12, 95% CI −0.23 to 0). Subgroup analysis by diabetes status (≥ 50% of cohort with diabetes vs < 50% with diabetes) found similar results for death or dependency and neurologic deficit.
Starting intravenous insulin within the first 24 hours of acute ischemic stroke to maintain normoglycemia does not reduce death or dependency but increases the risk for hypoglycemia.
*NS = not significant; other abbreviations defined in Glossary. RRR, RRI, NNT, NNH, and CI calculated from data in article using a fixed-effect model.
Paul G. Wasielewski, Ken Uchino. Review: Insulin to maintain normoglycemia within 24 hours of ischemic stroke does not reduce death or dependency. Ann Intern Med. 2011;155:JC6–5. doi: 10.7326/0003-4819-155-12-201112200-02005
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Published: Ann Intern Med. 2011;155(12):JC6-5.
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism, Neurology.
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