The Effect of a Liberal Approach to Glucose Control in Critically Ill Patients with Type 2 Diabetes: A Multicenter, Parallel-Group, Open-Label Randomized Clinical Trial.

2022-10-01

Poole, Alexis P

Finnis, Mark E

Anstey, James

Bellomo, Rinaldo

Bihari, Shailesh

Biradar, Vishwanath

Doherty, Sarah

Eastwood, Glenn M

Finfer, Simon

French, Craig J

Heller, Simon

Horowitz, Michael

Kar, Palash

Kruger, Peter S

Maiden, Matthew J

Mårtensson, Johan

McArthur, Colin J

McGuinness, Shay P

Secombe, Paul J

Tobin, Antony E

Udy, Andrew A

Young, Paul J

Deane, Adam M

blood glucose

critical illness

diabetes

hypoglycemia

intensive care

Journal Article

0000-0001-7553-8620

0000-0003-4345-3213

0000-0002-3428-3083

0000-0002-7620-5577

10.1164/rccm.202202-0329OC

Rationale: Blood glucose concentrations affect outcomes in critically ill patients, but the optimal target blood glucose range in those with type 2 diabetes is unknown. Objectives: To evaluate the effects of a "liberal" approach to targeted blood glucose range during ICU admission. Methods: This mutlicenter, parallel-group, open-label randomized clinical trial included 419 adult patients with type 2 diabetes expected to be in the ICU on at least three consecutive days. In the intervention group intravenous insulin was commenced at a blood glucose >252 mg/dl and titrated to a target range of 180-252 mg/dl. In the comparator group insulin was commenced at a blood glucose >180 mg/dl and titrated to a target range of 108-180 mg/dl. The primary outcome was incident hypoglycemia (<72 mg/dl). Secondary outcomes included glucose metrics and clinical outcomes. Measurements and Main Results: By Day 28, at least one episode of hypoglycemia occurred in 10 of 210 (5%) patients assigned the intervention and 38 of 209 (18%) patients assigned the comparator (incident rate ratio, 0.21 [95% confidence interval (CI), 0.09 to 0.49]; P < 0.001). Those assigned the intervention had greater blood glucose concentrations (daily mean, minimum, maximum), less glucose variability, and less relative hypoglycemia (P < 0.001 for all comparisons). By Day 90, 62 of 210 (29.5%) in the intervention and 52 of 209 (24.9%) in the comparator group had died (absolute difference, 4.6 percentage points [95% CI, -3.9% to 13.2%]; P = 0.29). Conclusions: A liberal approach to blood glucose targets reduced incident hypoglycemia but did not improve patient-centered outcomes. Clinical trial registered with Australian New Zealand Clinical Trials Registry (ACTRN 12616001135404).

link

American Journal of Respiratory and Critical Care Medicine 2022; 206(7): 874-882

American Journal of Respiratory and Critical Care Medicine