Stephen M. Pastores, MD, FACP, FCCP, FCCM
What are the benefits and harms of intensive insulin therapy (IIT) to achieve glycemic control in hospitalized patients?
Included studies assessed the effects of IIT (continuous intravenous insulin infusion, glucose-insulin-potassium, glucose-insulin, or subcutaneous insulin) in hospitalized patients. Studies of fixed-dose infusions were excluded. Primary outcome was short-term mortality (during or within 28 d of intensive care unit [ICU] or hospital stay). Secondary outcomes included mortality at 90 or 180 days, severe hypoglycemia (blood glucose levels < 2.2 mmol/L [< 40 mg/dL]), and infection (incident sepsis or other infections).
MEDLINE and Cochrane Database of Systematic Reviews (to end of Jan 2010); ClinicalTrials.gov; and reference lists of relevant studies, reviews, and editorials were searched for randomized controlled trials. Experts were consulted. 31 trials met the inclusion criteria; patients were in ICU or perioperative settings or had acute myocardial infarction or stroke. None of the trials were blinded.
Meta-analysis showed that IIT did not reduce short-term mortality (Table); similar results were found when stratifying for blood glucose levels achieved in the IIT group (< 6.7 mmol/L [< 120 mg/dL]) or the percentage of patients with diabetes (< 25%). Meta-analysis also showed that IIT did not reduce mortality at 90 or 180 days and increased risk for severe hypoglycemia (Table). IIT may reduce the risk for infection (Table), although results across studies were inconsistent.
In hospitalized patients, intensive insulin therapy does not reduce mortality, increases risk for severe hypoglycemia, and may reduce infection rates.
Intensive insulin therapy (IIT) vs control in hospitalized patients*
*NS = not significant; other abbreviations defined in Glossary. Weighted event rates, RRI, RRR, and CI calculated from data in article; NNH, NNT, and CI calculated from control event rate and relative risk in article based on a random-effects model.
†Death during or within 28 d of intensive care unit or hospital stay.
‡Significant heterogeneity (I2 = 58%, P = 0.011)
§Incident sepsis or other infections (wound infection, urinary tract infection, pneumonia, or a combination).
||Significant heterogeneity (I2 = 51%, P = 0.011).
Pastores SM. Review: Intensive insulin therapy does not reduce mortality but increases severe hypoglycemia in hospitalized patients. Ann Intern Med. ;155:JC1–12. doi: 10.7326/0003-4819-155-2-201107190-02012
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Published: Ann Intern Med. 2011;155(2):JC1-12.
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism, Hospital Medicine.
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