Poor Glycemic Control After Ischemic Stroke Linked to Poor Outcomes
Patients who don’t have an adequate reduction in glucose levels were more likely to experience poor outcomes after stroke.
Results from a new study recently published in the European Journal of Neurology confirm that poor glucose control is a frequent problem with conventional treatments for hyperglycemia following acute stroke, and leads to poor stroke outcomes. The multicenter Glycemia in Acute Stroke II (GLIAS-II) study investigators reported a 2-fold higher risk of death or dependence in nonresponders to standard glucose therapy 3 months after an acute ischemic stroke (AIS).
GLIAS-II was a multicenter prospective observational study of a cohort of 213 patients (age 18 to 85) with AIS onset within 24 hours. Within the first 48 hours after AIS, 97 patients (47.5%) reached capillary glucose levels higher than 155 mg/dL, which the study protocol indicated should be reduced to maintenance levels of 120 to 150 mg/dL. Despite this recommended threshold for treatment, the investigators found that only 71.1% (69 of 97) of eligible patients were actually treated for hyperglycemia. Decision to treat was at physician discretion, and patients who were treated were more likely to have had a prior diagnosis of diabetes mellitus, while only 1 of 22 patients with moderate hypoglycemia was treated.
Only 16% of treated patients (n=11) had an adequate response to therapy, while the remaining 84% (n=58) who did not achieve glucose reductions to <155 mg/dL were considered nonresponders. There were no marked differences between the groups in stroke severity. Nonresponders to glycemic management therapies showed a significant trend toward poor stroke outcomes including death at 3 month follow-up. Although treatments varied by physician preference, there were no significant differences according to type of treatment.
“Patients who had a poor response to corrective treatment for hyperglycemia more frequently had a prior diagnosis of metabolic syndrome and higher comorbidity,” study coinvestigator Blanca Fuentes, MD, of the Stroke Center at the Neurosciences Research IdiPAZ Health Research Institute and University Hospital La Paz in Madrid, Spain, told Neurology Advisor, which supported previous contentions by the GLIAS-II investigators that post-stroke hyperglycemia represents a modifiable post-AIS prognostic indicator.2
The investigators concluded that reductions to glucose levels <155 mg/dL using any traditional therapy counterbalanced the harmful impact of post-stroke hyperglycemia. “Currently, we are not planning to expand this study to evaluate other doses or duration of treatments,” Dr Fuentes said, noting that, “we addressed ‘conventional treatment' according to clinical guidelines. As there is [a] paucity of evidence regarding the optimal insulin regimen for acute stroke patients, only randomized clinical trials would answer this question and there is an ongoing clinical trial that is exploring this issue. We will wait to know its results.”
The study was limited by its observational design, which the investigators chose to avoid ethical concerns of attempting a clinical trial comparing active treatment with placebo. Patient groups were not equally balanced and the groups were small, which limited data interpretation, and patients who responded appeared to be healthier than nonresponders.
- Fuentes B, Sanz-Cuesta BE, Gutiérrez-Fernández M, et al. Glycemia in acute stroke II study: a call to improve post-stroke hyperglycemia management in clinical practice. Eur J Neurol. 2017;24(9):1091-1098.
- Fuentes B, Castillo J, San Jose B, et al. The prognostic value of capillary glucose levels in acute stroke: the GLycemia in Acute Stroke (GLIAS) study. Stroke. 2009;40: 562-568.