DIABETES AND

STROKEDR SUDHIR KUMAR MD (MED) DM

(NEURO)

CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, HYDERABAD

My Talk Would Cover:

Diabetes as a risk factor for stroke,

Sugar control in patients with acute stroke,

Sugar control in post-stroke patients,

Diabetes: Risk factor for stroke

Type 2 DM is associated with 2- to 3-fold increase in the risk of stroke.

About 10% of newly diagnosed T2DM patients develop stroke within the first 5 years of diagnosis,

The absolute risk of stroke is higher in older people (1% in 30-44 years versus 20% for >75 years old),

However, the relative risk of stroke (as compared to general population) is higher in younger people (5.6 times)

(Stroke,2007)

Factors in T2DM Predicting an

Increased Stroke Risk (1)

Proteinuria (OR: 3.23)

High systolic BP (OR:3.1)

High diastolic BP (OR: 3.3)

FBS > 200 mg% (OR: 1.8)

HbA1C> 9.5% (OR: 1.7)

(Stroke, 1999)

Factors in T2DM Predicting an

Increased Stroke Risk (2)

Hyperuricemia: Hazard ratio of 1.9 above mean uric

acid >5 mg% (Stroke, 1998)

Age>60 (Hazard ratio 4.8 versus those <50)

(Arch Int Med, 1999)

Diabetes as a Risk Factor for

Stroke in Women

Systematic review and meta-analysis of 64 cohort

studies between 1966 to 2013,

Pooled maximum-adjusted RR was 2.3 in women and

1.8 in men,

Compared with men with Type 2 DM, women with

Type 2 DM had a 27% greater risk of stroke. (Lancet,

2014)

Compared with men with Type 1 DM, women with

Type 1 DM had a 37% greater risk of stroke. (Lancet

Diabetes Endocrinol, 2015)

Prediabetes and Risk of Stroke

Prediabetes defined as FBS 100-125 m% did not

show an increase in risk of stroke,

Prediabetes defined as FBS 110-125 m% showed a

modest increase in risk of stroke (RR 1.21, p=0.03),

Impaired glucose tolerance resulted in modest

increase in the risk of stroke (RR 1.26, P<0.001),

(BMJ, 2012)

Hyperglycemia and Acute

Stroke (1)

Among patients admitted with stroke, 40-50% have diabetes mellitus (Stroke, 2009)

Additional 20% have hyperglycemia without any history of diabetes, termed as stress hyperglycemia,

So, a total 0f 60-70% of patients with acute stroke have hyperglycemia at admission.

Admission plasma glucose>110 mg% and HbA1C> 6.2% are good predictors of (undiagnosed) diabetes mellitus in patients with acute stroke, (Age Ageing, 2004)

Hyperglycemia and Acute

Stroke (2)

Patients with hyperglycemia and acute stroke have

prolonged hospital stay and incur higher

hospitalization costs (Neurology 2002)

Hyperglycemia at admission in patients with stroke

results in poor functional outcome at 3 months

(Neurology,1999)

Hyperglycemia independently increases the risk of

death at 90 days, 1 year and 6 years after stroke (all

p<0.01) (Neurology 2002)

Hyperglycemia and Acute

Stroke (3)

Hyperglycemia leads to: a) Lesser salvage of

mismatch tissue from infarction and b) Increase in

infarct size/volume over time, thus resulting in poorer

outcomes, as based on MRI diffusion-perfusion

studies

Acute hyperglycemia increases brain lactate

production and facilitates conversion of hypoperfused

at-risk tissue into infarction.

(Ann Neurology 2002)

Sugar Control in Acute Stroke

Setting

Strict sugar control would lower the sugars, thereby, improving functional outcomes; however, it may also result in hypoglycemia, resulting in brain damage.

GIST-UK trial: Patients with blood sugar between 108-306 mg% were treated with G-K-I infusions to maintain capillary glucose between 70-125 mg%.

No difference in mortality or severe disability was seen at 90 days after stroke, as compared to placebo group.

(Lancet Neurol 2007)

Tight Sugar Control Leads to

More Hypoglycemia

Glucose regulation in acute stroke patients (GRASP)

trial (Stroke, 2009)

3 arms- tight control (70-110 mg%), loose control (70-

200mg%) and control usual care (70-300mg%)

Insulin infusion was used to achieve the targets,

The overall rates of hypoglycemia (<55 mg%) were

5% in loose and control usual care groups, whereas it

was 30% in the tight group.

Intensive Insulin Therapy leads to

Larger Infarct growth

INSULINFARCT study (Stroke, 2012)

180 patients with MRI proven ischemic stroke (NIHSS score 5-25) were enrolled.

Received intensive insulin therapy (IIT) or usual subcutaneous insulin for 24 hours

95% within IIT group and 67% in subcutaneous insulin group had sugar within 126 mg%

Infract growth was lower in subcutaneous insulin group

Functional outcome and death rates were similar at 90 days.

American Stroke Association

Guideline

Maintain plasma glucose levels within 140 to 180

mg% in the first 24 hours,

Close monitoring should be done to detect

hypoglycemia,

For patients being considered for IV thrombolysis,

blood sugar should be within 50-500 mg% range.

(Stroke,2013)

Sugar Control in Post-stroke

Period

Sugar control is important in patients with stroke to prevent recurrence of stroke,

Diabetes mellitus and age are two most important predictors for stroke recurrence,

About 9% of recurrent strokes are attributable to diabetes mellitus,

Diabetes is also linked to the presence of multiple infarcts on brain scan.

Goal for HbA1C level is less than 7%.

(Stroke, 2006)

CONCLUSIONS Diabetes and prediabetes are important risk factors for

stroke,

Majority of patients with acute stroke have hyperglycemia,

Hyperglycemia worsens the outcome in stroke patients,

IIT is not useful in acute stroke setting,

Moderate sugar control is advisable in acute stroke setting,

HbA1C should be less than 7% in post-stroke patients.

THANKS

drsudhirkumar@yahoo.com

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