In 2001, a paper by van den Berghe and colleagues was published in the New England Journal of Medicine. It described a trial of intensive blood sugar control in critically ill patients and reported improved survival with intensive glucose treatment using insulin.
This study led to a substantial increase in aggressive hyperglycemia treatment known as “tight glycemic control” in the intensive care unit.
In 2009, another paper refuted the results of the first. The NICE SUGAR study enrolled 6000 critically ill patients, randomizing 3000 of them to tight glycemic control. The key result:
- mortality was higher (27.5% v. 24.9%) in the intensive insulin treatment arm
After this widely cited study, guess what happened to patients with hyperglycemia. Was tight glycemic control abandoned? Amazingly, No!
A recent study in JAMA reported that tight glycemic control continued without significant change after NICE SUGAR. Fewer dangerous hypoglycemia events occurred, but efforts to normalize high blood sugar continued as if the NICE SUGAR study never happened. Is it unethical to continue therapies that have been demonstrated to cause harm? Yes. Why does it happen?
This result betrays the bias towards action among physicians. Many of us have a hard time doing nothing, even when that is the most appropriate course of action.
The JAMA paper argues for de-adoption of useless therapies, like tight glycemic control. It is likely that evolutionary medicine can help promote de-adoption of harmful interventions by re-defining what is abnormal and should be treated versus what is normal and should be left alone.
Unfortunately abandoning useless therapies is harder than it might first appear. We still perform angioplasties on patients with stable angina, for instance. We give oxygen to patients having heart attacks. We still give IV fluids to trauma victims in the ambulance. The difficulty of changing practice is covered in a recent article by Howard and Gross: Producing Evidence to Reduce Low-Value Care
Evolutionary medicine has a role to play in rejecting useless therapies. In fact, there is great overlap between evolutionary medicine and the less is more movement in a variety of medical specialties.
Read about an evolutionary medicine complements a non-interventionist approach here: The New Normal
This area of research has great translational potential and will be a topic we cover this August at the 4th annual meeting of ISEMPH, the International Society for Evolution, Medicine, and Public Health.
van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345(19):1359-1367.
Finfer S, Chittock DR, Su SY, et al; NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-1297.
Niven D, Rubenfeld G, Kramer A, Stelfox H. Effect of Published Scientific Evidence on Glycemic Control in Adult Intensive Care Units. JAMA Intern Med. 2015 Mar 16. doi: 10.1001/jamainternmed.2015.0157.
Emergency Physician, Educator, Researcher, interested in the microbiome, evolution, and medicine
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