What is the most appropriate management for an elderly male patient with diabetes mellitus (DM) and hypertension (HTN), as well as dyslipidemia, who had an ischemic stroke a few weeks ago and was managed with antiplatelets and physiotherapy, now presents with fatigue and has hyperglycemia?

Management of Hyperglycemia in Post-Stroke Elderly Diabetic Patient

The most appropriate management is B - Observe with initiation of subcutaneous basal-bolus insulin therapy targeting glucose range of 140-180 mg/dL, not insulin infusion or warfarin. 1, 2

Why Subcutaneous Insulin, Not Insulin Infusion

Intravenous insulin infusion is not indicated for mild-to-moderate hyperglycemia in this clinical scenario. 1 The key considerations are:

• Insulin infusion is reserved for persistent hyperglycemia >200 mg/dL during the first 24 hours after stroke, not for routine management weeks post-stroke 1, 2
• 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 (DM, HTN, dyslipidemia), hypoglycemia may be more immediately dangerous than moderate hyperglycemia due to age-related reduced counter-regulatory hormone responses 1, 3

The Correct Approach: Subcutaneous Insulin Regimen

Initiate 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, 2

Target glucose range:

• 140-180 mg/dL is the recommended target per American Heart Association/American Stroke Association guidelines 1, 2
• Avoid glucose levels <80 mg/dL as hypoglycemia is particularly dangerous in elderly patients with diabetes 1, 2

Monitoring protocol:

• Monitor glucose every 6 hours initially 1, 2
• Check potassium levels before and during insulin therapy to avoid hypokalemia 1, 2

Why Not Warfarin

Warfarin has absolutely no role in managing hyperglycemia and is irrelevant to this clinical question 1

Additional considerations:

• 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 (no atrial fibrillation or cardioembolic source mentioned) 1
• Antiplatelet therapy remains the standard for atherosclerotic stroke prevention in diabetic patients 4, 5

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, 3, 2

Long-Term Management Considerations

Glycemic targets:

• For patients with multiple comorbidities like this patient, target HbA1c of 8% is appropriate rather than aggressive control 1, 3
• The risks of intensive control outweigh benefits in elderly patients with multiple comorbidities 1, 3

Blood pressure management:

• Target blood pressure <140/90 mmHg (or <130/80 mmHg per some guidelines) given the diabetes and stroke history 1, 4, 5
• ACE inhibitors or ARBs are preferred agents for blood pressure control in diabetic patients with stroke 4, 5, 6

Lipid management:

• Continue statin therapy targeting LDL <100 mg/dL (or <70 mg/dL for very high-risk patients) 7, 4, 5
• Statin therapy is essential for secondary stroke prevention regardless of baseline cholesterol 4, 5

Addressing the Fatigue

The fatigue in this patient is likely multifactorial:

• Hyperglycemia itself can cause fatigue and should improve with glucose control 8
• Post-stroke fatigue is common and may persist for weeks to months 7
• Ensure evaluation for other reversible causes (anemia, thyroid dysfunction, depression) if fatigue persists despite glucose control 7