An 84‑year‑old man with diabetes mellitus, hypertension, and dyslipidemia who suffered an ischemic stroke two days ago and is on antiplatelet therapy and physiotherapy now presents with fatigue and an elevated random blood glucose (~200 mg/dL); what is the most appropriate next step in management: start warfarin, observe, or start insulin infusion?

Management Recommendation

For this 84-year-old man with an ischemic stroke 2 days ago presenting with fatigue and a random blood glucose of 11 mmol/L (~200 mg/dL), the most appropriate management is B - Observe, while initiating subcutaneous insulin therapy for glucose control. Warfarin is not indicated without atrial fibrillation or cardioembolic source, and continuous insulin infusion is reserved for severe hyperglycemia (>180 mg/dL persistently or >300 mg/dL) in ICU settings, not for stable ward patients 2 days post-stroke. 1

Why Not Warfarin (Option A)

• Routine warfarin anticoagulation is not indicated for non-cardioembolic ischemic stroke. It should be reserved exclusively for patients with proven atrial fibrillation or other specific cardioembolic indications. 1
• Antiplatelet agents (aspirin or clopidogrel) are the standard for secondary stroke prevention in non-cardioembolic stroke, and this patient is already appropriately on antiplatelet therapy. 1
• Starting warfarin without a clear indication increases bleeding risk without added benefit in non-cardioembolic stroke. 1

Why Not Insulin Infusion (Option C)

• Continuous IV insulin infusion is recommended only when random glucose persistently exceeds 180 mg/dL (10 mmol/L) or reaches severe hyperglycemia (>300 mg/dL). 1
• In non-ICU settings (such as a general ward 2 days after stroke), subcutaneous insulin is the preferred route for glycemic control rather than IV infusion. 1
• This patient's glucose of 11 mmol/L (198 mg/dL) does not meet the threshold for IV insulin therapy. 1
• Do not use IV insulin for modest hyperglycemia in stable non-ICU patients; subcutaneous insulin provides comparable efficacy with a better safety profile. 1

Appropriate Management: Observe with Subcutaneous Insulin

Glucose Management Strategy

• The target glucose range for hospitalized stroke patients is 140-180 mg/dL (7.8-10 mmol/L). 2
• Initiate a basal-bolus subcutaneous insulin regimen when oral intake is adequate, starting at 0.3 U/kg total daily dose (approximately 50% basal once daily and 50% rapid-acting before meals). 1
• Avoid using sliding-scale insulin as the sole regimen because it is associated with both hypoglycemia and hyperglycemia and increases the risk of hospital complications. 1

Monitoring Protocol

• Check blood glucose before meals and at bedtime to allow timely titration of insulin doses. 1
• If blood glucose remains >140 mg/dL, monitor every 6 hours in the first 24-48 hours for patients with known diabetes. 2
• Do not target glucose <140 mg/dL aggressively in elderly patients, as tighter control raises hypoglycemia risk without proven benefit and may cause permanent brain injury. 1

Addressing the Fatigue

• Fatigue is a common post-stroke symptom and does not by itself indicate acute deterioration requiring aggressive intervention. 1
• Medical complications occur in the majority of acute-stroke patients; at least one adverse event was reported in 88% of patients in stroke cohorts. 1
• Ensure comprehensive evaluation for other causes: anemia, electrolyte disturbances, infection, or medication side effects. 2

Continued Stroke Care

• Continue antiplatelet therapy for secondary stroke prevention and to reduce the risk of DVT/PE in ischemic-stroke patients. 1
• Ensure adequate hydration and early mobilization to help prevent deep-vein thrombosis and pulmonary embolism, which are major post-stroke complications. 1
• Continue physiotherapy as already initiated. 2

Critical Pitfalls to Avoid

• Do not initiate warfarin without a clear indication (such as atrial fibrillation) because it increases bleeding risk without added benefit in non-cardioembolic stroke. 1
• Do not use IV insulin infusion for glucose levels <180 mg/dL in stable ward patients - this represents overtreatment and increases hypoglycemia risk. 1
• Avoid aggressive glucose lowering to <140 mg/dL - the GIST trial showed no benefit and potential harm from intensive glucose control in stroke patients. 2
• Do not overlook hypoglycemia - it can cause permanent brain damage and mimic stroke symptoms. 2

Secondary Prevention Optimization

• Blood-pressure control should aim for a target <130/80 mmHg, using an ACE inhibitor or ARB as first-line therapy. 1
• High-intensity statin therapy (e.g., atorvastatin 80 mg daily) targeting LDL <2.0 mmol/L reduces recurrent-stroke risk by approximately 22-30%. 1
• Address all vascular risk factors: diabetes control, dyslipidemia management, and hypertension optimization. 3, 4