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| |  Intensive Insulin Therapy Does Not Benefit Patients With Septic Shock Treated With Corticosteroids CHICAGO -- January 26, 2010 -- Treating adults with septic shock with intensive insulin therapy to counter elevated blood glucose levels associated with corticosteroid therapy did not result in a reduced risk of in-hospital death, compared with patients who received conventional insulin therapy, according to a study published in the January 27 issue of JAMA. The researchers also found that adding a 2nd corticosteroid to treatment did not significantly reduce the risk of death within the hospital. Djillali Annane, MD, Hôpital Raymond Poincaré, Garches, France, and colleagues with the Corticosteroids and Intensive Insulin Therapy for Septic Shock (COIITSS) trial examined whether normalisation of blood glucose levels with intensive insulin treatment would improve outcomes for adults with septic shock treated with hydrocortisone. The researchers also analysed the benefit of adding fludrocortisone to hydrocortisone therapy. The randomised trial, which included 509 adults with septic shock who had received hydrocortisone treatment, was conducted from January 2006 to January 2009 in 11 intensive care units (ICU) in France. Patients were randomly assigned to 1 of 4 groups: continuous intravenous insulin infusion with hydrocortisone alone; continuous intravenous insulin infusion with hydrocortisone plus fludrocortisone; conventional insulin therapy with hydrocortisone alone; or conventional insulin therapy with intravenous hydrocortisone plus fludrocortisone. Hydrocortisone was administered every 6 hours, and fludrocortisone was administered once a day for 7 days. At hospital discharge, 117 of 255 patients (45.9%) treated with intensive insulin therapy died and 109 of 254 patients (42.9%) treated with conventional insulin therapy died. No significant difference existed between treatment groups for any of the secondary outcome measures, such as the median number of days that surviving patients spent in the ICU in the intensive insulin group (10) versus for those in the conventional insulin group (9); the median length of stay in the hospital for the intensive insulin group (24 days) versus those in the conventional insulin group (22 days); the median vasopressor-free days for each group was 4; and the median mechanical ventilation-free days was 10 for the experimental group versus 13 days for the control group. Patients treated with intensive insulin experienced significantly more episodes of severe hypoglycemia than those in the conventional treatment group. Regarding the outcomes of adding fludrocortisone to therapy, at hospital discharge, 42.9% of the patients in the fludrocortisone-treated group died and 45.8% of patients in the conventional insulin therapy group died. “No significant difference in overall mortality existed between the fludrocortisone-treated patients and the controls,” the authors wrote. “Nor did significant differences exist between the 2 groups for the survivors’ ICU and hospital lengths of stay, for the number of vasopressor-free days, and for mechanical ventilation-free days.” “The current study showed no evidence to support a strategy of intensive insulin therapy aimed at maintaining blood glucose levels in the range of 80 to 110 mg/dL for treating septic shock with corticosteroids,” they wrote. “The current data do not support the routine use of oral fludrocortisone in addition to hydrocortisone when physicians decide to introduce corticosteroids in the management of a patient with septic shock.” SOURCE: JAMA
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