A 70-year-old female with diabetes mellitus, hypertension, and dyslipidemia, two days after an ischemic stroke treated with antiplatelet therapy and physiotherapy, now presents with fatigue, normal vital signs, and a random blood glucose of 12.6 mmol/L; what is the most appropriate next step in management?

Management of Hyperglycemia in Post-Stroke Patient

Observe the patient (Option A) is the most appropriate management, as the random blood glucose of 12.6 mmol/L (227 mg/dL) does not require immediate insulin intervention in this stable post-stroke patient with normal vital signs.

Rationale for Observation

The patient's glucose level of 12.6 mmol/L (227 mg/dL) falls into a range where immediate aggressive treatment is not indicated based on current stroke guidelines:

• The American Heart Association recommends treating hyperglycemia only when blood glucose persistently exceeds 180 mg/dL (10.0 mmol/L), with a target range of 140-180 mg/dL for critically ill patients 1, 2
• This patient's single random glucose measurement of 227 mg/dL does not meet the threshold for "persistent" hyperglycemia requiring immediate insulin therapy 2
• The patient is stable (normal vital signs) and two days post-stroke, not in the hyperacute phase where glucose management is most critical 1

Why Not Insulin (Option C)?

While the glucose is elevated, immediate insulin therapy is not warranted:

• There is no clinical evidence that targeting blood glucose to a particular level during acute ischemic stroke improves outcomes 1, 2
• The GIST-UK trial, the only large randomized trial of hyperglycemia treatment in acute stroke, showed no benefit from insulin therapy and the trial was underpowered 1, 2
• The main risk from aggressive hyperglycemia correction in acute stroke is hypoglycemia, which can cause permanent brain damage and worsen ischemic injury 2
• Insulin should be initiated only for persistent hyperglycemia starting at a threshold of 180 mg/dL, not a single elevated reading 2, 3

Appropriate Monitoring Strategy

The correct approach is to observe and monitor:

• Recheck blood glucose to determine if hyperglycemia is persistent 2
• If glucose persistently exceeds 180 mg/dL (10.0 mmol/L), then initiate subcutaneous insulin with a target range of 140-180 mg/dL 2, 4
• Monitor for symptoms of hyperglycemia (polyuria, polydipsia, altered mental status) 4
• The patient's fatigue may be related to the stroke itself rather than the mild hyperglycemia 1

Why Not Other Options?

Warfarin (Option B) is inappropriate because:

• The patient is already on antiplatelet therapy as indicated 1
• There is no indication given for anticoagulation (no atrial fibrillation, cardioembolic source, or other specific indication mentioned)
• Warfarin decisions are unrelated to the glucose management question

tPA (Option D) is contraindicated because:

• The patient is 2 days post-stroke, well beyond the 4.5-hour window for thrombolytic therapy 1
• tPA is only for acute ischemic stroke within hours of onset, not for delayed presentations

Common Pitfalls to Avoid

• Do not aggressively lower glucose to normoglycemia (<140 mg/dL) in acute stroke settings, as this increases hypoglycemia risk without proven benefit 2, 3
• Do not treat a single elevated glucose reading without confirming persistence 2
• Avoid sliding scale insulin alone without a proper basal-bolus regimen if insulin becomes necessary 4
• Remember that hyperglycemia in acute stroke is common (>40% of patients) and often stress-related, not always requiring immediate intervention 1