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 B - Observe, with initiation of subcutaneous insulin therapy targeting glucose 140-180 mg/dL, not insulin infusion. The patient's random blood sugar of 11 mmol/L (approximately 198 mg/dL) represents mild hyperglycemia that requires treatment, but warrants subcutaneous insulin rather than intravenous infusion, and warfarin has no role in this clinical scenario. 1

Why Not Insulin Infusion (Option C)

• Intravenous insulin infusion is not indicated for this level of hyperglycemia. The American Heart Association/American Stroke Association guidelines recommend treating elevated glucose concentrations in the range of 140-180 mg/dL, and reserve aggressive intervention for persistent hyperglycemia >200 mg/dL during the first 24 hours after stroke. 1

• The patient is 2 weeks post-stroke, well beyond the acute phase where intensive insulin protocols might be considered. Tight glucose control (80-110 mg/dL) using insulin infusions has demonstrated increased incidence of systemic and cerebral hypoglycemic events and possibly increased mortality risk. 2

• In elderly patients with multiple comorbidities (diabetes, hypertension, dyslipidemia), hypoglycemia may be more immediately dangerous than moderate hyperglycemia. This is particularly critical given age-related reduced counter-regulatory hormone responses. 1, 3

Why Not Warfarin (Option A)

• Warfarin has no role in managing hyperglycemia. The patient is already appropriately managed with antiplatelet therapy for secondary stroke prevention. 2

• There is no indication for anticoagulation based on the information provided (no atrial fibrillation, cardioembolic source, or other specific indication mentioned). 2

The Correct Approach: Observe with Subcutaneous Insulin Initiation

Immediate Management

• Initiate subcutaneous basal-bolus insulin regimen targeting glucose range of 140-180 mg/dL. The American Diabetes Association recommends starting 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

• Monitor glucose every 6 hours initially and check potassium levels before and during insulin therapy to avoid hypokalemia, as recommended by the American Geriatrics Society. 1

• Avoid glucose levels <80 mg/dL (4.4 mmol/L) as hypoglycemia is particularly dangerous in elderly patients with diabetes who are at increased risk of severe hypoglycemic events. 1, 3

Critical Pitfalls to Avoid

• Never use sliding-scale insulin alone as the single regimen. The American Diabetes Association explicitly advises against this approach as it results in undesirable hypoglycemia and hyperglycemia with increased risk of hospital complications. 1

• Avoid sulfonylureas, particularly glyburide and chlorpropamide, in this elderly patient. The American Geriatrics Society explicitly contraindicates chlorpropamide due to its prolonged half-life and escalating hypoglycemia risk with age. 1, 3

Long-Term Glycemic Targets

• For this patient with multiple comorbidities (diabetes, hypertension, dyslipidemia, recent stroke), target HbA1c of 8% is appropriate rather than aggressive control. The American Diabetes Association recommends less stringent targets for patients with complex/intermediate health status to avoid hypoglycemia risks that outweigh benefits. 1, 4

• Blood pressure target should be <140/90 mmHg given the diabetes and stroke history, with ACE inhibitors or ARBs as preferred agents. 2, 4, 5

Addressing the Fatigue

• The fatigue may be multifactorial: related to the recent stroke, suboptimal glucose control (RBS 11 mmol/L = 198 mg/dL), or other post-stroke complications. 2

• Ensure evaluation for post-stroke complications including depression, sleep disorders, and medication side effects, while optimizing glucose control. 2, 6

Monitoring Strategy

• Regular glucose monitoring is essential to titrate insulin doses and prevent both hyperglycemia and hypoglycemia. Self-monitoring of blood glucose may help reduce serious hypoglycemia risk in older adults using insulin. 3

• Assess for hypoglycemia awareness at every visit, as impaired hypoglycemia awareness is common in elderly patients and increases risk. 3