What is the most appropriate management for an old male patient with diabetes mellitus (DM) and hypertension (HTN), dyslipidemia, who had an ischemic stroke 2 weeks ago, now presenting with fatigue and hyperglycemia?

Management of Hyperglycemia in Post-Stroke Diabetic Patient

The most appropriate management is subcutaneous insulin therapy (not insulin infusion), targeting glucose levels of 140-180 mg/dL, with careful monitoring to avoid hypoglycemia. None of the three options listed are ideal—warfarin is not indicated without evidence of atrial fibrillation or cardioembolic source, observation ignores dangerous hyperglycemia, and insulin infusion is unnecessarily aggressive for this subacute presentation.

Rationale for Active Glucose Management

• Persistent hyperglycemia >200 mg/dL during the first 24 hours after stroke independently predicts expansion of infarct volume and worse outcomes, making glucose control essential even 2 weeks post-stroke 1
• The American Heart Association/American Stroke Association recommends treating elevated glucose concentrations when they exceed 200 mg/dL, with a reasonable target range of 140-180 mg/dL 2, 1
• Hyperglycemia increases tissue acidosis through anaerobic glycolysis, promotes free radical production, affects the blood-brain barrier, increases brain edema risk, and is associated with hemorrhagic transformation 1

Specific Treatment Approach for This Patient

Start subcutaneous basal-bolus insulin regimen at 0.3 units/kg/day total daily dose, divided as half basal insulin once daily and half rapid-acting insulin before meals if oral intake is adequate 1

Why Not the Listed Options:

• Warfarin (Option 1): Not indicated unless there is atrial fibrillation or cardioembolic source identified—the patient is already on antiplatelet therapy which is appropriate for atherosclerotic stroke 3
• Observe (Option 2): Dangerous approach given that hyperglycemia >200 mg/dL requires treatment to prevent infarct expansion and poor outcomes 2, 1
• Insulin infusion (Option 3): Overly aggressive for a subacute presentation (2 weeks post-stroke); continuous insulin infusion is reserved for critically ill patients or hyperglycemic crises, not for routine management of elevated glucose in stable post-stroke patients 2

Critical Monitoring Requirements

• Monitor glucose every 6 hours initially to ensure adequate control without hypoglycemia 1
• Check potassium levels before and during insulin therapy to avoid hypokalemia, which occurs in approximately 50% of cases during hyperglycemia treatment and is associated with increased mortality when severe 2, 1
• Avoid glucose levels <80 mg/dL, as hypoglycemia may be more immediately dangerous than moderate hyperglycemia, particularly in elderly patients with diabetes who are at increased risk of severe hypoglycemic events 1, 4

Long-Term Management Considerations

Given this patient's multiple comorbidities (DM, HTN, dyslipidemia, recent stroke), he falls into the "complex/intermediate health status" category:

• Target A1C of <8.0% rather than aggressive control, to balance efficacy with hypoglycemia risk 4
• Blood pressure target of <140/90 mmHg with ACE inhibitor or ARB as first-line agent 4, 3
• Statin therapy for lipid management regardless of baseline LDL-C, as this reduces cardiovascular risk 4, 3
• Continue antiplatelet therapy for secondary stroke prevention 3

Common Pitfalls to Avoid

• Never use sliding-scale insulin alone as the single regimen, as it results in undesirable hypoglycemia and hyperglycemia and increased risk of hospital complications 1
• Avoid sulfonylureas (particularly glyburide and chlorpropamide) in older adults due to high risk of prolonged hypoglycemia 1
• Do not use glucose-insulin-potassium infusion routinely, as it is not indicated and potentially harmful 2
• Avoid overtreatment—regularly reassess treatment intensity and simplify complex regimens when possible 4