Management: Observation with Subcutaneous Insulin
For this elderly diabetic patient 2 days post-ischemic stroke presenting with fatigue and a random blood glucose of 11 mmol/L (≈200 mg/dL), observation with subcutaneous insulin is the most appropriate management—not warfarin or insulin infusion.
Rationale for Observation Over Aggressive Intervention
Why Not Insulin Infusion?
The glucose level of 11 mmol/L (200 mg/dL) does not meet the threshold for IV insulin therapy. Guidelines recommend initiating continuous IV insulin infusion only when glucose exceeds 180 mg/dL (10 mmol/L) persistently or reaches severe levels (>1000 mg/dL) 1, 2.
This patient is in a non-ICU setting 2 days post-stroke. Subcutaneous insulin is the preferred agent for glycemic control in non-critical care settings, not IV infusion 1.
The target glucose range for most hospitalized patients is 140-180 mg/dL (7.8-10 mmol/L). More stringent goals of 110-140 mg/dL may be appropriate for select patients with acute ischemic neurological events, but only if achievable without significant hypoglycemia 1.
This patient's glucose of 200 mg/dL is only modestly elevated and can be managed with subcutaneous basal-bolus insulin regimen starting at 0.3 units/kg total daily dose 1.
Why Not Warfarin?
The patient is already on appropriate antiplatelet therapy. Australian stroke guidelines clearly state that antiplatelet therapy should be used for ischemic stroke to prevent DVT/PE and for secondary stroke prevention 1.
Warfarin is not indicated for noncardioembolic ischemic stroke. Guidelines explicitly state that routine anticoagulation is not recommended for people with noncardioembolic ischemic stroke or TIA 1.
Warfarin would only be considered if the patient had nonrheumatic atrial fibrillation, which is not mentioned in this case 1.
Appropriate Management Strategy
Glucose Management in Non-ICU Post-Stroke Setting
Initiate subcutaneous basal-bolus insulin regimen if the patient has adequate oral intake, starting at 0.3 units/kg total daily dose—half as basal insulin once daily and half as rapid-acting insulin before meals 1.
Monitor blood glucose regularly (before meals and at bedtime) to titrate insulin doses appropriately 1.
Target glucose levels of 140-180 mg/dL (7.8-10 mmol/L) to balance glycemic control with hypoglycemia risk, which is particularly important in elderly patients 1.
Avoid sliding scale insulin as the sole regimen, as it results in undesirable hypoglycemia and hyperglycemia and increased risk of hospital complications 1.
Monitoring for Fatigue
Fatigue is a common post-stroke symptom and does not necessarily indicate acute deterioration requiring aggressive intervention 1.
Continue observation for neurological changes, as medical complications are common after acute stroke, with at least one adverse event reported in 88% of patients 1.
Ensure adequate hydration and early mobilization to help prevent DVT/PE, which are major complications post-stroke 1.
Secondary Stroke Prevention
Continue antiplatelet therapy as already initiated—this is the cornerstone of secondary prevention 1, 3, 4.
Optimize blood pressure control with target <130/80 mmHg using ACE inhibitors or ARBs as first-line agents 5, 4.
Initiate high-intensity statin therapy (atorvastatin 80 mg daily) targeting LDL <2.0 mmol/L to reduce recurrent stroke risk by 22-30% 5, 3, 4.
Critical Pitfalls to Avoid
Do not use IV insulin for modest hyperglycemia in stable non-ICU patients, as subcutaneous insulin is safer and equally effective 1.
Do not target glucose <140 mg/dL aggressively, as this increases hypoglycemia risk without proven benefit, and hypoglycemia can cause permanent brain damage in elderly patients 1.
Do not initiate warfarin without clear indication (such as atrial fibrillation), as it increases bleeding risk without benefit in noncardioembolic stroke 1.
Do not overlook the importance of multifactorial risk factor management—blood pressure control, statin therapy, and antiplatelet agents are more important than aggressive glucose lowering for stroke prevention 3, 4, 6, 7.