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Meta-Analysis
. 2014 Jan 23;2014(1):CD005346.
doi: 10.1002/14651858.CD005346.pub4.

Insulin for glycaemic control in acute ischaemic stroke

M Fernanda Bellolio  1 , Rachel M Gilmore, Latha Ganti
Affiliations
Meta-Analysis

Insulin for glycaemic control in acute ischaemic stroke

M Fernanda Bellolio et al. Cochrane Database Syst Rev. .

Abstract

Background: People with hyperglycaemia concomitant with an acute stroke have greater mortality, stroke severity, and functional impairment when compared with those with normoglycaemia at stroke presentation. This is an update of a Cochrane Review first published in 2011.

Objectives: To determine whether intensively monitoring insulin therapy aimed at maintaining serum glucose within a specific normal range (4 to 7.5 mmol/L) in the first 24 hours of acute ischaemic stroke influences outcome.

Search methods: We searched the Cochrane Stroke Group Trials Register (September 2013), CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to September 2013), EMBASE (1980 to September 2013), CINAHL (1982 to September 2013), Science Citation Index (1900 to September 2013), and Web of Science (ISI Web of Knowledge) (1993 to September 2013). We also searched ongoing trials registers and SCOPUS.

Selection criteria: Randomised controlled trials (RCTs) comparing intensively monitored insulin therapy versus usual care in adults with acute ischaemic stroke.

Data collection and analysis: We obtained a total of 1565 titles through the literature search. Two review authors independently selected the included articles and extracted the study characteristics, study quality, and data to estimate the odds ratio (OR) and 95% confidence interval (CI), mean difference (MD) and standardised mean difference (SMD) of outcome measures. We resolved disagreements by discussion.

Main results: We included 11 RCTs involving 1583 participants (791 participants in the intervention group and 792 in the control group). We found that there was no difference between the treatment and control groups in the outcomes of death or dependency (OR 0.99, 95% CI 0.79 to 1.23) or final neurological deficit (SMD -0.09, 95% CI -0.19 to 0.01). The rate of symptomatic hypoglycaemia was higher in the intervention group (OR 14.6, 95% CI 6.6 to 32.2). In the subgroup analyses of diabetes mellitus (DM) versus non-DM, we found no difference for the outcomes of death and disability or neurological deficit. The number needed to treat was not significant for the outcomes of death and final neurological deficit. The number needed to harm was nine for symptomatic hypoglycaemia.

Authors' conclusions: After updating the results of our previous review, we found that the administration of intravenous insulin with the objective of maintaining serum glucose within a specific range in the first hours of acute ischaemic stroke does not provide benefit in terms of functional outcome, death, or improvement in final neurological deficit and significantly increased the number of hypoglycaemic episodes. Specifically, those people whose glucose levels were maintained within a tighter range with intravenous insulin experienced a greater risk of symptomatic and asymptomatic hypoglycaemia than those people in the control group.

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Conflict of interest statement

None of the authors has any conflicts of interest to disclose.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Dependency or death, Outcome 1 Dependency or death at the end of the follow‐up.
1.2
1.2. Analysis
Comparison 1 Dependency or death, Outcome 2 Death.
1.3
1.3. Analysis
Comparison 1 Dependency or death, Outcome 3 Diabetes mellitus versus no diabetes mellitus.
1.4
1.4. Analysis
Comparison 1 Dependency or death, Outcome 4 Less than 30 days versus 90 days of follow‐up.
2.1
2.1. Analysis
Comparison 2 Functional neurological outcome, Outcome 1 NIHSS or ESS at the end of the follow‐up.
2.2
2.2. Analysis
Comparison 2 Functional neurological outcome, Outcome 2 Independent in daily activities.
2.3
2.3. Analysis
Comparison 2 Functional neurological outcome, Outcome 3 Diabetes mellitus versus no diabetes mellitus.
2.4
2.4. Analysis
Comparison 2 Functional neurological outcome, Outcome 4 Less than 30 days versus 90 days of follow‐up.
3.1
3.1. Analysis
Comparison 3 Hypoglycaemia, Outcome 1 Symptomatic hypoglycaemia.
3.2
3.2. Analysis
Comparison 3 Hypoglycaemia, Outcome 2 Hypoglycaemia (with or without symptoms).
4.1
4.1. Analysis
Comparison 4 Mean glucose level, Outcome 1 Mean glucose level.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Azevedo 2009 {published data only (unpublished sought but not used)}
    1. Azevedo JRA, Azevedo RP, Miranda MA, Costa NNR, Araujo LO. Management of hyperglycemia in patients with acute ischemic stroke: comparison of two strategies. Critical Care 2009;13 Suppl 3:48.
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THIS 2008 {published and unpublished data}
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Vinychuk 2005 {published data only}
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Vriesendorp 2009 {published data only}
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References to studies excluded from this review

CIMT Trial {published data only}
    1. Lundby Christensen L, Almdal T, Boesgaard T, Breum L, Dunn E, Gade‐Rasmussen B, et al. Study rationale and design of the CIMT trial: the Copenhagen Insulin and Metformin Therapy trial. Diabetes, Obesity & Metabolism 2009;11:315‐22. - PubMed
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GIST 1999 {published data only}
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GLUCOVAS {published data only}
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References to ongoing studies

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SHINE {published data only}
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References to other published versions of this review

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