How to manage blood sugar to prevent and treat stroke?

Abnormal glucose metabolism or diabetes has been recognized as an important risk factor for cerebrovascular diseases, especially ischemic stroke/transient ischemic attack (TIA)
.

In order to allow stroke patients to receive standardized blood glucose management, to do a good job in the secondary prevention of stroke, and to reduce the risk of recurrence of stroke patients, the guidelines for stroke blood glucose management are specially formulated for the reference of clinicians
.

01 Blood glucose management in the acute phase of ischemic stroke/TIA ➤Hyperglycemia 1.
For patients with acute ischemic stroke/TIA, blood glucose should be measured and monitored as soon as possible
.

2.
For patients with acute ischemic stroke/TIA who have been diagnosed with diabetes or have hyperglycemia, glycosylated hemoglobin (HbA1c) should be measured
.

3.
Patients with acute ischemic stroke/TIA who have been diagnosed with diabetes or have hyperglycemia should consult with a specialist in endocrinology after admission
.

4.
Patients with persistent hyperglycemia, when the blood sugar is higher than 10.
0mmol/L, insulin therapy should be given.
In the acute phase, insulin is the first choice, which can control the blood sugar between 7.
8 and 10.
0mmol/L
.

Under the premise of no obvious hypoglycemia, it may be appropriate for some patients to achieve more stringent blood glucose targets, such as 6.
1-7.
8mmol/L
.

5.
Basal insulin or basic meal-time insulin regimen is the first choice for non-critically ill patients
.

It is not recommended to routinely use intravenous insulin to intensively lower blood sugar levels
.

6.
For mild acute ischemic stroke/TIA with normal eating, the original hypoglycemic treatment plan can be maintained, including oral hypoglycemic treatment
.

7.
When the blood sugar is less than 3.
9mmol/L, the treatment plan should be evaluated and improved to prevent the occurrence of hypoglycemia
.

➤Hypoglycemia 1.
For all acute stroke/TIA patients, blood glucose should be measured as soon as possible
.

2.
For patients with blood glucose <3.
9mmol/L and normal consciousness, oral glucose treatment with 15-20g is preferred, and sugar-containing carbohydrates can also be used for treatment
.

3.
If the fingertip blood glucose measurement still has hypoglycemia after 15 minutes of oral glucose, repeat the above treatment
.

If the fingertip blood glucose measurement returns to normal, the patient should eat to prevent the recurrence of hypoglycemia
.

4.
Once asymptomatic hypoglycemia or severe hypoglycemia occurs, the treatment plan for lowering blood sugar should be re-evaluated
.

5.
Once patients with insulin treatment have asymptomatic hypoglycemia or blood glucose <3.
0mmol/L, the target value of blood glucose control should be increased to avoid recurrence of asymptomatic hypoglycemia
.

02 Blood glucose management in ischemic stroke/TIA prevention ➤Benefits and goals of blood glucose control (1) For patients with ischemic stroke/TIA without a history of abnormal glucose metabolism, blood glucose should be screened, fasting blood glucose, and glycation should be checked Hemoglobin and/or oral glucose tolerance test, but it should be noted that the results of fasting blood glucose and oral glucose tolerance test can be affected by the acute stroke event itself
.

(2) For newly diagnosed diabetic patients, strict blood sugar control can reduce the incidence of long-term cardiovascular disease (including stroke)
.

(3) The use of SGLT-2 inhibitors and GLP-1 receptor agonists in patients with ischemic stroke/TIA combined with type 2 diabetes can reduce the occurrence of cardiovascular events
.

(4) The use of GLP-1 receptor agonists in patients with type 2 diabetes with cardiovascular risk factors can reduce the occurrence of cardiovascular events (including stroke)
.

(5) In the long-term blood glucose management of patients with ischemic stroke/TIA, it is recommended to control the HbA1c level at <7.
0% (average plasma glucose is 8.
6mmol/L)
.

In order to achieve the goal of HbA1c≤7.
0%, most patients with type 1 or type 2 diabetes set the fasting blood glucose or pre-meal blood glucose target to 4.
0-7.
0 mmol/L, and the 2-hour postprandial blood glucose target to 5.
0 to 10.
0 mmol/L
.

In the choice of hypoglycemic drugs, priority can be given to hypoglycemic drugs that have clinical evidence to reduce the risk of stroke events, such as metformin, pioglitazone, and GLP-1 receptor agonists
.

(6) In the absence of hypoglycemia or other serious adverse reactions, young patients, patients with a short history of diabetes, long life expectancy and no serious cardiovascular disease can choose a more stringent target HbA1c level (<6.
5%) (average Plasma glucose is 7.
8mmol/L) For people with a history of severe hypoglycemia, short life expectancy, severe microvascular or macrovascular complications or other serious complications, as well as a long history of diabetes and the use of multiple drugs including insulin For patients who have difficulty controlling blood sugar, consider increasing the target HbA1c level to 8.
0% (average plasma glucose 10.
2mmol/L)
.

➤Drug recommendation (1) For type 2 diabetes, use metformin as the first-line drug to improve blood sugar and reduce the risk of atherosclerotic cardiovascular disease (ASCVD)
.

(2) In type 2 diabetic patients with previous ASCVD, it is recommended to use GLP-1 receptor agonists or SGLT-2 inhibitors as part of the blood glucose management plan
.

(3) After the application of metformin, if the patient's HbA1c>7.
0% and have ASCVD risk factors, consider giving GLP-1 receptor agonists or SGLT-2 inhibitors to improve blood sugar control and reduce the risk of stroke/TIA
.

(4) For type 2 diabetes patients with stroke/TIA, if the blood sugar lowering treatment plan is a combination of two drugs or a combination of multiple drugs and the glycosylated hemoglobin has reached the standard, one of the drugs can be considered to be GLP-1 receptor activation Agent or SGLT-2 inhibitor
.

03 Blood glucose management in patients with spontaneous cerebral hemorrhage 1.
For patients with cerebral hemorrhage, blood sugar levels should be detected and monitored as soon as possible
.

Patients with hypoglycemia should be given sugar supplement treatment as soon as possible, and the goal of correcting blood sugar is normal blood sugar to avoid excessive blood sugar
.

When blood glucose is greater than 10.
0mmol/L, an appropriate blood glucose treatment plan should be formulated.
Routine use of intravenous insulin for intensive blood glucose lowering treatment is not recommended, and attention should be paid to avoid hypoglycemia
.

2.
For patients after the acute phase of cerebral hemorrhage, please refer to the relevant content of "Benefits and Goals of Blood Sugar Control" in "Glucose Management in Secondary Prevention of Ischemic Stroke/TIA" in this guide
.

04 Blood glucose management for severe stroke patients For any type of severe stroke patients, it is recommended that insulin therapy should be given when the blood glucose persists> 10.
0 mmol/L, and the recommended target blood glucose control target is 7.
8 to 10.
0 mmol/L
.

For some patients, it may be reasonable to set a blood glucose target of 6.
1 to 7.
8mmol/L on the premise that severe hypoglycemia does not occur
.

Yimaitong is compiled from: Medical Administration and Hospital Administration.
Chinese Guidelines for Stroke Prevention and Treatment (2021 Edition)—3.
Chinese Guidelines for Blood Glucose Management for Stroke Prevention and Treatment.
2021-8-31.