Intravenous insulin treatment in acute stroke: a systematic review and meta-analysis of randomized controlled trials

Introduction Poststroke hyperglycemia has been associated with unfavorable outcome. Several trials investigated the use of intravenous insulin to control hyperglycemia in acute stroke. This meta-analysis summarizes all available evidence from randomized controlled trials in order to assess its efficacy and safety. Methods We searched PubMed until 15/02/2013 for randomized clinical trials using the following search items: 'intravenous insulin' or 'hyperglycemia', and 'stroke'. Eligible studies had to be randomized controlled trials of intravenous insulin in hyperglycemic patients with acute stroke. Analysis was performed on intention-to-treat basis using the Peto fixed-effects method. The efficacy outcomes were mortality and favorable functional outcome. The safety outcomes were mortality, any hypoglycemia (symptomatic or asymptomatic), and symptomatic hypoglycemia. Results Among 462 potentially eligible articles, nine studies with 1491 patients were included in the meta-analysis. There was no statistically significant difference in mortality between patients who were treated with intravenous insulin and controls (odds ratio: 1 center dot 16, 95% confidence interval: 0 center dot 89-1 center dot 49). Similarly, the rate of favorable functional outcome was not statistically different (odds ratio: 1 center dot 01, 95% confidence interval: 0 center dot 81-1 center dot 26). The rates of any hypoglycemia (odds ratio: 8 center dot 19, 95% confidence interval: 5 center dot 60-11 center dot 98) and of symptomatic hypoglycemia (odds ratio: 6 center dot 15, 95% confidence interval: 1 center dot 88-20 center dot 15) were higher in patients treated with intravenous insulin. There was no heterogeneity across the included trials in any of the outcomes studied. Conclusions This meta-analysis of randomized controlled trials does not support the use of intravenous insulin in hyperglycemic stroke patients to improve mortality or functional outcome. The risk of hypoglycemia is increased, however.