Managing Hyperglycemia in Acute Ischemic Stroke Patients
To the Editor:
The guidelines for the early management of adults with ischemic stroke1 published in the May 2007 issue of Stroke offer new recommendations regarding the management of hyperglycemia in this population. This is a very common problem, occurring in about one-third of nondiabetic and in most diabetic stroke patients,2 so the care of large numbers of people will be influenced by these recommendations. We agree with the authors that this is an important issue and recognize that the recommendations are largely consensus recommendations (Grade C) due to a lack of evidence. Despite mounting evidence in critically ill patients,3 there remains a dearth of information related to efficacy of specific glucose-lowering interventions in ischemic stroke. Among critically ill patients, diabetics respond to tight glucose control differently and may be harmed rather than benefiting3; we do not know whether this is true of stroke patients. We therefore would encourage the readership to maintain clinical equipoise as the stroke community works to complete the clinical trials that will hopefully clarify the risk benefit ratio of various treatments in the hyperglycemic acute ischemic stroke population.
Sources of Funding
Drs Johnston, Hall and Bleck are supported by NIH-NINDS R01 NS050192, the Glucose Regulation in Acute Stroke Patients (GRASP) Trial.
Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EFM. Guidelines for the early management of adults with ischemic stroke. Stroke. 2007; 38: 1655–1711.
Allport L, Baird T, Butcher K, MacGregor L, Prosser J, Colman P, Davis S. Frequency and temporal profile of poststroke hyperglycemia using continuous glucose monitoring. Diabetes Care. 2006; 29: 1839–1844.
Van den Berghe G, Wilmer A, Milants I, Wouters PJ, Bouckaert B, Bruyninckx F, Bouillon R, Schetz M. Intensive insulin therapy in mixed medical/surgical intensive care units: benefit versus harm. Diabetes. 2006; 55: 3151–3159.