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Canadian Pharmacists Association
Canadian Pharmacists Association
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Chapter 27: Management of Stroke in Diabetes

Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada

Introduction
  • Diabetes is an important modifiable risk factor for a first ischemic stroke, and the combination of diabetes and stroke is a major cause of morbidity and mortality worldwide.
    • Estimates of risk of ischemic stroke in people with diabetes range from a 2- to 3-fold increase in men and a 2- to 5-fold increase in women.
    • Diabetes also doubles the risk of stroke recurrence, and stroke outcomes are significantly worse among patients with diabetes, with increased hospital and long-term stroke mortality, more residual neurological and functional disability, and longer hospital stays.
  • Evidence from large clinical trials performed in patients with diabetes supports the need for aggressive and early intervention to target the cardiovascular (CV) risks of patients to prevent the onset, recurrence and progression of acute stroke.
  • General risk factors associated with acute stroke include hypertension, dyslipidemia, and atrial fibrillation.
  • Risk factors associated with acute stroke that are specific to diabetes include insulin resistance, central obesity, impaired glucose tolerance and hyperinsulinemia. These factors are associated with an excess risk of stroke disease.
  • A comprehensive, multifactorial strategy addressing healthy behaviours, blood pressure, lipids, glucose and the possible use of vascular protective medications to reduce overall CV morbidity and mortality among people with diabetes is essential to reduce the risk of this potentially devastating complication.
Diabetes Management in the Acute Period
  • Patients with ischemic stroke or transient ischemic attack (TIA) should be screened for diabetes with a fasting plasma glucose, glycated hemoglobin (A1C) or 75 g oral glucose tolerance test soon after admission to hospital [Grade D, Consensus].
  • The management of hyperglycemia in acute stroke (occurring within 24 hours of stroke symptom onset) remains controversial; the evidence to support tight glucose control immediately following acute ischemic stroke has not been supportive.
  • A Cochrane Systematic Review evaluated randomized controlled trials comparing intensively monitored insulin therapy (target blood glucose range 4.0 to 7.5 mmol/L) vs. usual care in adult patients with acute ischemic stroke, with or without diabetes.
    • There was no difference between treatment and control groups or between those with diabetes vs. those with no diabetes in the outcome of death or disability and dependence or final neurological deficit.
    • Symptomatic hypoglycemia was higher in the intervention group.
    • It was concluded that the use of insulin to maintain glucose levels of 4.0 to 7.5 mmol/L in the first 24 hours after stroke symptom onset is not beneficial compared to usual care and may be harmful with increased hypoglycemia. Therefore, there is no glucose target specific to patients presenting with stroke.
    • However, the recommendation for the majority of non-critically ill hospitalized patients to have their glucose levels maintained below 10.0 mmol/L remains applicable to those admitted with acute stroke.
  • All patients with diabetes and ischemic stroke or TIA should receive the same treatments that are recommended for patients with ischemic stroke or TIA without diabetes since they benefit equally [Grade D, Consensus].

For definitions of the levels of evidence cited in this chapter, please refer to the Guideline Recommendations: Levels of Evidence.

If you would like more details on this topic, please visit the Canadian Diabetes Association Clinical Practice Guidelines: Chapter 27.