Nice-Sugar

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Information about Nice-Sugar

Published on October 17, 2016

Author: IsabellaLai

Source: slideshare.net

1. NICE-SUGAR OVMC LANDMARK TRIALS SERIES

2. NICE-SUGAR: Intensive versus Conventional Glucose Control in Critically Ill Patients

3. BACKGROUND  Hyperglycemia is common in critically ill patients  Hyperglycemia is associated with increased morbidity and mortality  Prior to the NICE-SUGAR trial, a study in post- surgical patients found decreased mortality with sugar levels between 80-110, but this was a single center study that could be prone to biases (eg Hawthorne effect)

4. CLINICAL QUESTION  In critically ill patients, how does intensive glycemic control compare to conventional glycemic control in reducing the risk of mortality?

5. DESIGN  Analysis: Intention-to-treat  Multicenter, non-blinded, parallel group, randomized, controlled trial  N=6,104  Intensive (n=3,054)  Conventional (n=3,050)  Setting: 42 centers  Primary outcome: 90-day mortality

6. POPULATION Inclusion Criteria  Expected to require ICU treatment for ≥3 consecutive days  Medical and surgical ICU patients Exclusion Criteria  None identified

7. INTERVENTIONS  Participants randomized to:  Intensive glycemic control (goal 81-108 mg/dL)  Conventional glycemic control (goal ≤180 mg/dL)  Glycemic control occurred with IV insulin infusion  Conventional glycemic control group (goal ≤180 mg/dL) was started on IV insulin infusion for glucose levels >180 and was discontinued for blood glucose <144, when the patient was eating, or was discharged from the ICU.

8. CRITICISMS  Inability to blind treating staff  The intensive insulin therapy arm had more participants that happen to receive corticosteroids. This created variability in glucose levels.

9. BOTTOM LINE  In medical ICU patients, intensive glycemic control (target 81-108 mg/dL) led to more deaths compared to conventional control (target≤180). Glucose Goal:140-180

10. DISCUSSION QUESTIONS  In the NICE-TRIAL, what is the optimal target for glucose therapy?  Can this data be extrapolated to inpatient medicine wards (in non-critically ill patients)?

11. DISCUSSION QUESTIONS  In the NICE-TRIAL, what is the optimal target for glucose therapy?  ANSWER: 140-180 mg/dL  Can this data be extrapolated to inpatient medicine wards (in non-critically ill patients)?  ANSWER: It depends! In non-critically ill patients, goal MORNING glucose can be <140 ONLY IF this can be safely achieved

12. BOARD-LIKE QUESTION 75 yo F is evaluated in the hospital for hip fracture. She has a history of DM2. Patient takes Atorvastatin, Metformin BID, Insulin Glargine 20 units qHS, Insulin Lispro 5 units qAC. Her average blood glucose level in the morning is 120 mg/dL. It is Sunday night, and your hospital does not do hip fracture repairs. Patient is scheduled to be transferred to neighboring county hospital on Monday morning. Laboratory is significant for HgA1c 7.9% and a plasma glucose of 210 mg/dL. ADAPTED from MKSAP 17 QUESTION Which is the most appropriate preoperative diabetic management for this patient? A. Discontinue Lispro. Start NPH because it is shorter acting than Lantus. B. Stop insulin glargine and insulin lispro, start IV insulin infusion C. Discontinue Glargine/Lispro. Continue Metformin and add sliding scale. D. Administer insulin glargine, but hold insulin lispro

13. BOARD-LIKE QUESTION Educational Objective: Managing DM2 medications in the preoperative setting Key Point: You should continue long-acting insulin while withhold shorting acting insulin during fasting prior to surgical intervention. Oral hypoglycemic are usually held in the inpatient setting ANSWER Which is the most appropriate preoperative diabetic management for this patient? A. Discontinue Lispro. Start NPH because it is shorter acting than Lantus. B. Stop insulin glargine and insulin lispro, start IV insulin infusion C. Discontinue Glargine/Lispro. Continue Metformin and add sliding scale. D. Administer insulin glargine, but hold insulin lispro

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