A diagnosis of diabetes at least doubles the risk of stroke ⁽¹⁾. Thus, a considerable proportion of patients presenting to hospital with acute stroke will have type 2 diabetes and less commonly type 1 diabetes.

All patients who present with stroke should have a capillary blood glucose checked on admission to hospital, as hyperglycaemia in stroke patients is common, and associated with worse outcomes ⁽²⁾. Whilst lowering blood glucose in people with diabetes during acute stroke has not been shown to significantly improve outcomes ^(3,4,5), glucose lowering with insulin does limit cerebral infarct size in animal studies ⁽⁶⁾.

In hospitalised stroke patients fed by the enteral route, the management of hyperglycaemia should be balanced against the risks of hypoglycaemia. Hypoglycaemia during the rest period between feeds is a potentially life-threatening event ⁽⁷⁾ and close monitoring of the patient is recommended at all times.

Thus, the focus in the management of hyperglycaemia should be the maintenance of blood glucose within an acceptable range whilst limiting the risk of hypoglycaemia. It is the recommendation of these guidelines that the diabetes inpatient team should be involved at the earliest opportunity to provide specialist guidance surrounding blood glucose control.

1. Blood glucose targets

• Fasting/Pre-feed 5-8mmol/l

• Feeding 6-12 mmol/l

• If CBG< 4mmol/l or persistently>12mmol/l on 2 consecutive occasions or evidence of ketonuria 2+ or ketonaemia >1.5 mmol/L then inform the DSN/Diab SpR or on-call medical team. If ketones are raised, do an urgent VBG to exclude DKA

2. Frequency of bedside glucose monitoring

• If Continuous feed – measure CBG pre-feed and then 4-6 hourly

• If intermittent feed – measure CBG pre feed, 4-6 hourly during feed and 2-hours post feed

• If bolus only feed – monitor CBG pre-feed, 2-hours post feed and 4-6 hourly during prolonged intervals between feeds

Monitor CBG hourly if receiving VRIII

Beware of risk of hypoglycaemia during fasted periods between feeds

Beware of hypoglycaemia as a cause of drowsiness in patients with stroke

3. Timing of insulin administration

If using pre-mixed insulin e.g. Humulin M3

• First dose at time of feed commencement – this is listed as ‘prefeed’ on EPIC frequency section

• Second dose at midpoint of the feed – this is listed as ‘midway through feed’ on EPIC frequency section

• 50% of the required insulin can be administered with each dose

If using a basal bolus regimen (basal and rapid acting analogue insulin)

• Basal insulin should be given at feed commencement

• Bolus doses of rapid acting analogue insulin may be administered at the start and mid-point of the feed or at the start and 6 hourly during the feed – you can use the pencil icon in the bottom right hand corner of the prescription box in EPIC to adjust the timing of the insulin

As the feed rate or volume increases, the subcutaneous insulin dose will need to be titrated appropriately – please ask the DSN or Diab SpR for help with this.

4. Actions to undertake if feed is stopped

• Whatever the reason for stopping the feed it is necessary to remember that insulin already administered will continue to drive the blood glucose down. The patient should thus be monitored for signs of hypoglycaemia and the CBG measured hourly, and more frequently (up to every 15 minutes) if symptoms or signs of hypoglycaemia are present.

• If the feed is stopped at an unplanned time and subcutaneous insulin is due, delay but do not omit the insulin dose – it is advised that the insulin dose should be given when the feed is recommenced.

5. Advice on interpretation of the HBA1C result

Known Diabetes

Refer to DSN if HBA1C is > 58 mmol/mol for optimisation of control

Not previously known to have diabetes

If fasting glucose is > 6.1mmol/L but < 7mmol/L or HBA1C is between 42-47 mmol/mol– this suggests ‘non-diabetic hyperglycaemia’

Please calculate their BMI – advise on weight reduction measures, e.g., healthy eating and regular exercise if applicable

Please ask the GP to refer to the NDPP (National Diabetes Prevention Program) on discharge and arrange for annual check of HBA1C on the Discharge letter

If fasting glucose is >7 mmol/l or HBA1C is 48 mmol/mol or above – this suggests diabetes

Please refer to the DSN for basic education and arrange for dietetic input pre discharge

Please refer for follow up in a GP led diabetic clinic unless advised otherwise by the diabetes team

1. Barrett Connor E, Khaw K-T. Diabetes mellitus: an independent risk factor for stroke? Am J Epidemiol. 1988;128:116-123

2. Bejot Y, Aboa-Beloue C, Hervieu M et al.The Deleterious Effect of Admission Hyperglycaemia on Survival and functional Outcome in Patients with Intracerebral Haemorrhage. Stroke 2012; 43(1): 243-5.

3. Gray CS, Hildreth AJ, Sandercock PA, O’Connell JE, Johnston DE, Cartlidge NE, Bamford JM, Lames OF, Alberti KGM. The UK Glucose Insulin in Stroke Trial (GIST-UK). Lancet Neurol 2007; 6:397-406.

4. Azevedo JR, Lima ER, Cossetti RJ, Azevedo RP. Intensive insulin therapy versus conventional glycaemic control in patients with acute neurological injury: a prospective controlled trial. Arq Neuropsiquiatr. 2007;65:733-8.

5. Bruno A, Kent TA, Coull BM, Shankar RR, Saha C, Becker KJ et al. Treatment of hyperglycaemia in ischaemic stroke (THIS): a randomised pilot trial. Stroke.2008;39:384-9.

6. Hamilton MG, Tranmer BI, Auer RN. Insulin reduction of cerebral infarction due to transient focal ischemia. J Neurosurg 1995.82 (2):262-8.

7. American Diabetes Association. Nutrition recommendations and Interventions for Diabetes: A position statement of the American Diabetes Association. Diabetes Care 2007.;30 Suppl1:S48-65.

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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