Diabetes as a risk factor
Diabetes is a risk factor for both small and large vessel stroke disease. Those with diabetes have a 2-4 times increased risk of stroke. This is in addition to an increased risk of cardiac and renal disease. Additional risk factors include being over age 55, black, previous stroke or heart disease, a family history of heart disease, being overweight and Smoking. The worldwide incidence of diabetes appears to be increasing. The issue is around faulty glucose regulation. Diabetes has a key role in stroke and is an integral part of ABCD2 scoring for TIAs and CHADSVASC for Assessing stroke risk in AF. Controlling BMS reduces microvascular (retinopathy, nephropathy, neuropathy) but less so much the macrovascular risks of stroke and coronary artery and peripheral vascular disease. Controlling blood pressure is key as well as smoking and diet and lipids. Risk factors including obesity, hypertension, and dyslipidaemia often co-exist in patients with DM that add on to stroke risk. The UKPDS study did show that intensive treatment of BP helped reduce the risk of stroke. target BP levels vary and current target are 130/85.
Managing Diabetes in the HASU
Glycaemic management during the inpatient enteral feeding of stroke patients with diabetes
- 4-6 hourly capillary blood glucose (CBG) monitoring of all patients presenting with stroke and diabetes or newly recognised hyperglycaemia.
- Refer patient to diabetes inpatient specialist nurse (DISN)/diabetes inpatient team (DIT) at earliest opportunity for individual assessment.
- Patients with type 1 diabetes should continue their basal insulin at all times – whether receiving insulin via the subcutaneous or intravenous route – and should not have insulin omitted.
- Continue subcutaneous basal analogue insulin (Glargine or Detemir) if patient treated with basal analogue insulin on admission.
- Target CBG 6-12 mmol/l during enteral feeding of people with diabetes.
- Early involvement of a dietitian to determine an appropriate feed regimen.
- Aim to minimise use of intravenous insulin infusions as far as possible – aim to establish patient on to subcutaneous insulin or glucose-lowering agents administered via the nasogastric tube (NGT) at the earliest opportunity.
- Premixed human insulin at start and midpoint of feed, or isophane insulin at start and, if necessary, the midpoint of feed are recommended first line options for glycaemic management of patients with poorly controlled type 2 diabetes during enteral feeding.
- Administration of soluble human insulin at the time of feed commencement is recommended for a bolus feeding regimen. For those patients prescribed Glargine or Detemir on admission to hospital and receiving continuous feeding with CBG>12 mmol/l, soluble human insulin may be administered at the start and, if necessary, midpoint of the feed.
- Resuspension of metformin powder administered via NGT may be useful as a sole treatment, or adjunct, for people with type 2 diabetes.
- Crushing of oral tablet medications for administration via NGT is not recommended.
- Monitor capillary glucose pre-feed and then 4-6 hourly when feed running; monitor hourly if feed unexpectedly switched off.
- Involve DISN/DIT immediately in event of hypoglycaemia or recurrent hyperglycaemia
Long term Management
- Eating a healthy balanced diet. Your diet should be low in salt, fat and sugar and include plenty of fruit and vegetables, high fibre foods and oily fish once or twice a week.
- Smoking cessation
- Weight loss
- Frequent exercise
- Reduced alcohol intake
- BP control
- Statin for lipids
- Treatment targets must be individualized. The optimal targets should be
- Glycated Haemoglobin A1C =7.0% in patients with type 1 or type 2 diabetes.
- Fasting plasma glucose (preprandial) plasma glucose target of 4.0 to 7.0 mmol/L
- Two-hour postprandial plasma glucose target is 5.0 to 10.0 mmol/L.
- If HbA1C targets cannot be achieved with a postprandial target of 5.0 to 10.0 mmol/L, further postprandial blood lowering, to 5.0 to 8.0 mmol/L, can be considered.
- Type 2 diabetes is associated with plasma lipid and lipid protein abnormalities that include low concentrations of HDL cholesterol, increases in small, dense, atherogenic LDL particles and elevated triglycerides
- Adults with diabetes and ischaemic stroke are at high risk of further vascular events and should also be treated with a statin to achieve a LDL cholesterol =2·0 mmol/l
- Unless contraindicated, low-dose acetylsalicylic acid (ASA) therapy (80 to 325 mg/day) is recommended in all patients with diabetes with evidence of stroke or cardiovascular disease
Blood pressure control in Diabetics is Important. Target < 140/80 mmHg
- Aggressive treatment of BP in those with type 2 diabetes reduces the risk of stroke and stroke mortality.
- Most diabetic patients will require > 1 antihypertensive agent.
- ACEIs and ARBs are more effective and are recommended as first choice medication for patients with DM.
References and further reading