What is the target blood glucose range for patients post tissue plasminogen activator (tPA) for stroke?

Blood Glucose Management After tPA Administration for Stroke

For patients who have received tissue plasminogen activator (tPA) for acute ischemic stroke, the target blood glucose range should be maintained between 140 to 180 mg/dL. 1

Evidence-Based Rationale

Hyperglycemia and Stroke Outcomes

• Persistent in-hospital hyperglycemia during the first 24 hours after acute ischemic stroke is associated with worse outcomes than normoglycemia 1
• Hyperglycemia has been linked to:
  • Increased infarct expansion
  • Higher risk of hemorrhagic transformation
  • Poorer functional outcomes
  • Increased length of hospital stay
  • Higher mortality at 30 days 1

Specific Concerns with tPA

• In patients who received tPA, the risk of symptomatic intracranial hemorrhage (sICH) increases by 75% per 100 mg/dL increase in blood glucose 1
• Blood glucose >158 mg/dL is associated with lower recanalization rates after tPA (16% vs 36.1%) 2
• Hyperglycemia may counteract the beneficial effects of tPA-induced recanalization 3

Management Protocol

Monitoring

• Document glucose levels on admission and monitor frequently during the post-tPA period 1
• For patients with admission glucose >140 mg/dL who received tPA, monitor glucose every 1-2 hours initially 1
• Consider continuous glucose monitoring for high-risk patients to detect both hyper- and hypoglycemic events 4

Treatment Thresholds

1. Initiate insulin therapy when blood glucose is ≥180 mg/dL 1
2. Target glucose range: 140-180 mg/dL 1
3. Avoid hypoglycemia: Maintain glucose >60 mg/dL 1

Treatment Approach

• For patients with severe or persistent hyperglycemia, critically ill patients, or those treated with tPA:
  • Use standardized intravenous insulin protocols for the first 24-48 hours 5
  • Then transition to subcutaneous insulin regimens 5
• For less severe hyperglycemia, subcutaneous insulin protocols can safely lower and maintain blood glucose below 180 mg/dL 1

Important Considerations and Pitfalls

Avoid Hypoglycemia

• Hypoglycemia (blood glucose <60 mg/dL) should be promptly treated in patients with acute ischemic stroke 1
• Aggressive glucose control protocols increase the risk of hypoglycemic events 5
• Hypoglycemic events occur more frequently during nighttime and in patients with normoglycemia at admission 4

Risk Stratification

• Admission glucose level is a predictor for both hypo- and hyperglycemic events after admission 4
• Patients with admission glucose >158 mg/dL have:
  • Lower recanalization rates with tPA (16% vs 36.1%)
  • Higher NIHSS scores at 48 hours (14.5 vs 7) 2

Monitoring Frequency

• More frequent monitoring is needed for:
  • Patients with type 1 diabetes
  • Those with hepatic or renal impairment
  • Patients on complicated feeding regimens 5

While the SHINE trial was investigating a tighter glucose control target (80-130 mg/dL) 1, current guidelines from the American Heart Association/American Stroke Association recommend the 140-180 mg/dL range as the most appropriate target that balances the risks of hyperglycemia against the dangers of hypoglycemia in the post-stroke setting 1.