DOI: 10.1097/CCM.0b013e3181932c7c

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Issn Print: 0090-3493

Publication Date: 2009/01/01


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Blood glucose control in critically ill patients: The impact of diabetes

Moritoki Egi; Rinaldo Bellomo

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We appreciate Dr. Krinsley’s interest in our study (1) and consider his previous work important (2). He also confirmed that in diabetic critically ill patients, hyperglycemia may have different biological and/or clinical implications. It is interesting that Dr. Krinsley showed that strict euglycemia (mean glucose level 70–99 mg/dL) among diabetics was independently associated with a decreased risk of mortality on multivariable analysis, which is in contrast with our findings. We believe this issue requires further investigation as diabetic patients make up a significant part (15%–20%) of all intensive care unit patients. This controversial issue has been recently played out in non-intensive care unit patients. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) (3) Study investigators reported that aggressive glucose control in type 2 diabetic patients to reduce glycated hemoglobin level from 8.3% to 6.4% significantly increased mortality compared with control therapy (reduction in HbA1c from 8.3% to 7.5%; all cause mortality: 5.0% vs. 4.0%, p = 0.04) (3). On the other hand, the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) study showed that more intensive therapy which slowly reduced the glycated hemoglobin level from 7.5% to 6.5% was associated with a nonsignificant beneficial trend in mortality (4).
There were important differences between ACCORD and ADVANCE in terms of blood glucose control (5) that may be relevant to our observations, particularly the speed of lowering of HbA1c levels: in ACCORD, there was a 0.35% absolute decrease per month within first 4 months. In contrast, in ADVANCE, there was a 0.08% absolute decrease per month within the first 6 months. These findings in the chronic setting showed an association between increased mortality and a four-fold faster reduction in HbA1c. They suggest that the rapid correction of glycemia in diabetic patients with chronic hyperglycemia might contribute to increased mortality.
Fortunately, in the forthcoming 6100 patients randomized, multicenter, controlled Normoglycemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation study, all measurements of blood glucose concentrations and information on the diagnosis of diabetes are being recorded together. The study will, therefore, provide us with the ability to evaluate the impact of diabetes on the effect of two different glycemic levels control. Until then, we advise caution about the possible dangers of too rapid a correction glycemia (intensive insulin therapy) in diabetic critically ill patients.
The authors have not disclosed any potential conflict of interest.
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