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

Management of Post-Stroke Hyperglycemia in Elderly Diabetic Patient

The most appropriate management is to observe the patient while initiating subcutaneous basal-bolus insulin therapy targeting glucose levels of 140-180 mg/dL, making option B (Observe) the correct answer, though this should be paired with appropriate subcutaneous insulin initiation rather than passive observation alone. 1

Why Insulin Infusion (Option C) is Inappropriate

• Intravenous insulin infusion is not indicated for mild-to-moderate hyperglycemia in a patient several weeks post-stroke. 1
• 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 in patients more than 2 weeks post-stroke. 1
• In elderly patients with multiple comorbidities (diabetes, hypertension, dyslipidemia, recent stroke), hypoglycemia may be more immediately dangerous than moderate hyperglycemia due to age-related reduced counter-regulatory hormone responses. 1
• IV insulin is reserved for persistent hyperglycemia >200 mg/dL during the first 24 hours after acute stroke, not for patients presenting weeks later with fatigue and elevated glucose. 1, 2

Why Warfarin (Option A) is Inappropriate

• Warfarin has no role in managing hyperglycemia. 1
• The patient is already appropriately managed with antiplatelet therapy for secondary stroke prevention. 1
• There is no indication for anticoagulation based on the information provided, such as atrial fibrillation or cardioembolic source. 1

The Correct Approach: Observe with Active Glucose Management

Initiate subcutaneous basal-bolus insulin regimen 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, 2

Target Glucose Range

• Target glucose range of 140-180 mg/dL to balance efficacy with hypoglycemia risk in elderly patients. 1, 2
• Avoid glucose levels <80 mg/dL as hypoglycemia is particularly dangerous in elderly patients with diabetes who are at increased risk of severe hypoglycemic events. 1, 2

Monitoring Strategy

• Monitor glucose every 6 hours initially. 1, 2
• Check potassium levels before and during insulin therapy to avoid hypokalemia. 1, 2
• Regular glucose monitoring is essential to titrate insulin doses and prevent both hyperglycemia and hypoglycemia. 1

Critical Pitfalls to Avoid

• Never use sliding-scale insulin alone as the single regimen, as it results in undesirable hypoglycemia and hyperglycemia with increased risk of hospital complications. 1, 2
• Avoid sulfonylureas, particularly glyburide and chlorpropamide, in elderly patients due to their prolonged half-life and escalating hypoglycemia risk with age. 1, 2
• Elderly hospitalized patients often experience failure of regulatory mechanisms, especially reduced release of glucagon and epinephrine in response to hypoglycemia, and fail to perceive neuroglycopenic and autonomic hypoglycemic symptoms. 1

Long-Term Glycemic Targets for This Patient

• For patients with multiple comorbidities (diabetes, hypertension, dyslipidemia, recent stroke), target HbA1c of 8% is appropriate rather than aggressive control. 1, 3
• This patient fits the "complex/intermediate health status" category, warranting less stringent glycemic targets to avoid hypoglycemia risks that outweigh benefits. 3, 2
• Blood pressure target should be <140/90 mmHg given the diabetes and stroke history, with ACE inhibitors or ARBs as preferred agents. 1, 4

Additional Cardiovascular Risk Management

• Continue antiplatelet therapy for secondary stroke prevention. 4
• Ensure statin therapy is optimized for lipid management regardless of baseline cholesterol levels. 3, 4
• Blood pressure should be treated with target of 140/80 mmHg as maximum, with ACE inhibitor as drug of choice. 4