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Diabetes Management The Treatment of Diabetes after an Acute Ischemic Stroke Geert Jan Biessels, MD, PhD 1 and L Jaap Kappelle, MD, PhD 1 1. Professor of Neurology, Department of Neurology, UMC Utrecht Stroke Center and Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands Abstract People with diabetes are at increased risk of ischemic stroke and outcome after stroke is worse. This paper reviews the treatment of patients with diabetes after ischemic stroke. First, management of hyperglycemia in the acute stage will be addressed. We will make the point that, despite the fact that admission hyperglycemia is a common risk factor for poor outcome after ischemic stroke, there is still much uncertainty about whether intensive glucose-lowering therapy after stroke benefits clinical outcome. Secondary prevention of further cardiovascular events after stroke is the other main topic of this review. We will show that there are important opportunities for the reduction of stroke risk in diabetes, through a rigorous evaluation and treatment of associated risk factors. Keywords Diabetes, ischemic stroke, prevention, treatment, outcome Disclosure: Geert Jan Biessels, MD, PhD, consults for and receives research support from Boehringer Ingelheim. L Jaap Kappelle, MD, PhD, has received speakers honoraria from Bayer and Boehringer Ingelheim. Acknowledgment: The research of Geert Jan Biessels, MD, PhD, is supported by grant 2010T073 from the Netherlands Heart Foundation. Received: July 17, 2012 Accepted: August 24, 2012 Citation: US Endocrinology, 2012;8(2):88–92 Correspondence: Geert Jan Biessels, MD, PhD, Department of Neurology, University Medical Center Utrecht G03.232, PO Box 85500, 3508 GA Utrecht, The Netherlands. E: g.j.biessels@umcutrecht.nl Diabetes and ischemic stroke are common conditions that often co-occur. The relationship between diabetes and stroke is bidirectional. On the one hand, people with diabetes have a more than two-fold increased risk of ischemic stroke compared to people without diabetes. 1 On the other hand, acute stroke can give rise to abnormalities in glucose metabolism, which in turn may affect outcome. 2 In the current review, which is based on a recent paper from our group in the Lancet Neurology, 3 we describe the management of diabetes both in the acute stage of stroke and in the longer term, with regard to secondary prevention. Diabetes and the Risk of Stroke A recent meta-analysis of prospective studies including 530,083 participants reported a hazard ratio for ischemic stroke of 2.3 (95 % confidence interval [CI] 2.0–2.7) in people with versus people without diabetes. 1 Considering that the estimated world-wide prevalence of diabetes in adults is around 10 %, this implies that one in eight to nine cases of stroke is attributable to diabetes. Diabetes is associated with different aetiological subtypes of ischemic stroke, including lacunar and athero- and cardioembolic strokes. 4–6 Moreover, the risk of atrial fibrillation, the major cause of thromboembolic stroke, is increased by 40 % in diabetes. 7 Diabetes-associated risk factors for stroke include diabetes-specific factors (e.g. hyperglycemia) and vascular risk factors (e.g. hypertension, dyslipidemia), but also genetic, demographic, and lifestyle factors. The contribution of these factors, 88 many of which are strongly interrelated, is likely to differ according to diabetes type and age. Hyperglycemia and Stroke Outcome Hyperglycemia occurs in 30–40 % of patients with an acute ischemic stroke. 2,8 The majority of these patients does not have a known history of diabetes. 2 In a proportion of patients hyperglycemia reflects pre-existing but unrecognised diabetes, but more often it is due to an acute stress response, commonly named ‘stress hyperglycemia’. Stress hyperglycemia is defined as a fasting glucose >6.9 mmol/l or a random glucose >11.1 mmol/l during hospital stay that spontaneously reverts to normal range after discharge. 9 Hence, glucose levels at admission generally do not distinguish between stress hyperglycemia and diabetes. In this setting, elevated glycated hemoglobin (HbA 1c ) levels (≥6.5 %) can help to identify previously undiagnosed diabetes. 9,10 Patients with ischemic stroke who are hyperglycemic at admission are at increased risk of poor outcome. Compared to normoglycemic patients, patients with hyperglycemia and a known history of diabetes have an elevated relative risk of in-hospital or 30-day mortality (unadjusted relative risk 2.0 [95 % CI 0.04–90.1]). 2 In those without a history of diabetes this risk is 3.3 (95 % CI 2.3–4.7). 2 The association between hyperglycemia and poor outcome primarily involves patients with large-vessel infarction. 11 In small-vessel ‘lacunar’ stroke, moderate hyperglycemia has even been associated with improved outcome. 8 © TOUCH MEDICAL MEDIA 2012