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Intensive glucose management again fails to help -- this time, in stroke
Intensive insulin therapy to maintain blood glucose in the normal range has immense intuitive appeal. Hyperglycemia is associated with bad outcomes in numerous conditions, and we have the tools at hand to rigorously control it. How could that not help people?
Unfortunately, intensive insulin therapy doesn't seem to help at all, and may harm patients. And because intensive glucose management is, well, intensive -- requiring additional resources to avoid hypoglycemia -- and without proven benefit, it has largely been abandoned in U.S. ICUs, where seeking a blood sugar less than 180 mg/dL is considered standard care.
Strokes have been one of the remaining conditions where tight glucose control was believed to be helpful. Abundant evidence suggests that high blood glucose after acute stroke is associated with worse outcomes.
The newly published SHINE randomized trial -- stopped for futility -- demonstrates that as in other conditions, targeting blood sugar less than 180 mg/dL is the best option in patients hospitalized for strokes.
Numerically more patients with liberal glucose control (<180 mg/dL) had better functional outcomes at 90 days (21.6% vs 20.5%, P=0.55, not statistically significant).
About one in 40 patients became severely hypoglycemic with intensive insulin therapy, compared to none in the liberal glucose control group.
Results were reported at the American Heart Association's International Stroke Conference.
Before the NIH-funded trial was stopped for futility, it enrolled 1,151 patients with acute strokes and hyperglycemia, with (80%) or without (20%) previously diagnosed diabetes. Median glucose at baseline was 188 mg/dL. In both groups, patients' glucose were quickly brought into the target range and maintained there.
The SHINE trial may have written the last line of the epitaph on the tombstone of intensive insulin therapy. As a leading stroke researcher put it, the trial leaves "no doubt" as to the lack of benefit in acute stroke, and "now you have a very clear answer. I wouldn't want to mount another trial." How often have you heard those words from an academic?