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

Management of Hyperglycemia in Post-Stroke Diabetic Patient

The most appropriate management is to observe the patient while initiating subcutaneous basal-bolus insulin therapy targeting glucose 140-180 mg/dL, making option B (Observe) the correct answer, though "observe" here means active glucose management with subcutaneous insulin, not passive observation. 1, 2

Why Subcutaneous Insulin, Not Insulin Infusion

• Intravenous insulin infusion (Option C) is contraindicated in this patient who is 2 weeks post-stroke with mild hyperglycemia. 1
• The American Heart Association/American Stroke Association reserves aggressive intervention with IV insulin only for persistent hyperglycemia >200 mg/dL during the first 24 hours after stroke—this patient is well beyond that acute window. 1, 3
• 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 like this patient (DM, HTN, dyslipidemia, recent stroke), hypoglycemia may be more immediately dangerous than moderate hyperglycemia due to age-related reduced counter-regulatory hormone responses. 1, 2

Why Not Warfarin

• Warfarin (Option A) has absolutely no role in managing hyperglycemia and is not indicated for this patient's stroke management. 1
• The patient is already appropriately managed with antiplatelet therapy for secondary stroke prevention following an ischemic stroke. 2
• There is no indication for anticoagulation based on the information provided, such as atrial fibrillation or confirmed cardioembolic source. 1

The Correct Approach: Active Glucose Management

• 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, 3
• Target glucose range of 140-180 mg/dL to balance efficacy with hypoglycemia risk in this elderly patient with multiple comorbidities. 1, 2, 3
• Monitor glucose every 6 hours initially and check potassium levels before and during insulin therapy to avoid hypokalemia. 1, 3
• 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, 3

Critical Monitoring Parameters

• Assess for hypoglycemia awareness at every visit, as impaired hypoglycemia awareness is common in elderly patients and increases severe hypoglycemia risk. 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
• Regular glucose monitoring is essential to titrate insulin doses and prevent both hyperglycemia and hypoglycemia. 1

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, 3
• Absolutely avoid sulfonylureas, particularly glyburide and chlorpropamide, in elderly patients due to their prolonged half-life and escalating hypoglycemia risk with age. 1, 2, 3
• Never target tight glucose control (80-110 mg/dL) in this elderly post-stroke patient, as this increases cerebral hypoglycemic events and possibly mortality. 1, 2

Long-Term Management Considerations

• Target HbA1c of 8% is appropriate for this patient with multiple comorbidities rather than aggressive control, to avoid hypoglycemia risks that outweigh benefits. 1, 2, 3
• Blood pressure target should be <140/90 mmHg given the diabetes and stroke history, with ACE inhibitors or ARBs as preferred agents. 1, 2, 4
• Continue antiplatelet therapy (aspirin 81-325 mg daily) for secondary stroke prevention. 2