Randomized Controlled Trial of Intensive Versus Conservative Glucose Control in Patients Undergoing Coronary Artery Bypass Graft Surgery: GLUCO-CABG Trial

Abstract

OBJECTIVEThe optimal level of glycemic control needed to improve outcomes in cardiac surgery patients remains controversial.RESEARCH DESIGN AND METHODSWe randomized patients with diabetes (n = 152) and without diabetes (n = 150) with hyperglycemia to an intensive glucose target of 100–140 mg/dL (n = 151) or to a conservative target of 141–180 mg/dL (n = 151) after coronary artery bypass surgery (CABG) surgery. After the intensive care unit (ICU), patients received a single treatment regimen in the hospital and 90 days postdischarge. Primary outcome was differences in a composite of complications, including mortality, wound infection, pneumonia, bacteremia, respiratory failure, acute kidney injury, and major cardiovascular events.RESULTSMean glucose in the ICU was 132 ± 14 mg/dL (interquartile range [IQR] 124–139) in the intensive and 154 ± 17 mg/dL (IQR 142–164) in the conservative group (P < 0.001). There were no significant differences in the composite of complications between intensive and conservative groups (42 vs. 52%, P = 0.08). We observed heterogeneity in treatment effect according to diabetes status, with no differences in complications among patients with diabetes treated with intensive or conservative regimens (49 vs. 48%, P = 0.87), but a significant lower rate of complications in patients without diabetes treated with intensive compared with conservative treatment regimen (34 vs. 55%, P = 0.008).CONCLUSIONSIntensive insulin therapy to target glucose of 100 and 140 mg/dL in the ICU did not significantly reduce perioperative complications compared with target glucose of 141 and 180 mg/dL after CABG surgery. Subgroup analysis showed a lower number of complications in patients without diabetes, but not in patients with diabetes treated with the intensive regimen. Large prospective randomized studies are needed to confirm these findings.

Management of hospitalized type 2 diabetes mellitus patients

“…[2,4] Data from trials, [5,6] using intensive glycemic control in patients in intensive care unit (ICU) failed to show a significant improvement in mortality and in some cases, showed an augmented mortality risk. The GLUCO-CABG trial, [7] in patients after cardiac surgery also demonstrated no differences in rates of complications and death between an intensive glucose management of 100-140 mg/dL and a traditional target of 140-180 mg/dL. However, more stringent objectives as 110-140 mg/dL may be appropriate for select patients if they are achievable without meaningful risk of hypoglycemia, for example, patients with acute myocardial infarction [8] or neurological events.…”

How do I manage hyperglycemia/post-transplant diabetes mellitus after allogeneic HSCT

“…82 Using continuous insulin infusion, a significant lower rate of complications was observed in non-diabetic patients treated with intensive (target glucose level, 100-140 mg/dL) versus conservative treatment regimen (141-180 mg/dL). 83 Therefore, based on the clinical scenario, continuous insulin infusion for basal insulin coverage or BBI may be used to achieve glucose control.…”

Blood glucose control using a computer-guided glucose management system in allogeneic hematopoietic cell transplant recipients

“…Using Glucommander it was recently shown that for patients without diabetes, complications during coronary artery grafting were less, maintaining glucose level between 100 and 140 mg/dL versus level of 141-180 mg/dL. 12 As the first step to prospectively evaluate the effect of this desired degree of glucose control in the HCT setting, we evaluated the feasibility of obtaining near normoglycemia in HCT patients using a CGGM. Despite the small number of patients enrolled on the study, we demonstrated that a narrow range of glucose levels between 100 and 140 mg/dL was attained 61% of the time while on CGGM, with only 10 episodes (0.9% of BG measurements and 0.2% of total time on study) of BG lower than 70 mg/dL and with no episodes of BG lower than 40 mg/dL.…”

“…[1][2][3] Recently, efforts have been made to control hyperglycemia during hospitalization, but results from clinical trials and retrospective analyses have demonstrated inconsistent outcomes associated with intensive insulin therapy. [4][5][6][7][8][9][10][11][12] There is also evidence that severe hypoglycemia (glucose o40 mg/dL) in hospitalized patients may have a detrimental effect on outcomes, including cardiac arrest, seizures, hypoglycemia-induced coma and mortality, 5,[13][14][15][16][17] thus limiting the efforts for meticulous glucose control in the hospital. In addition, recent evidence also suggests that glucose variability can be detrimental and increase mortality risk in hospitalized patients.…”