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A randomized trial finds no benefit with intensive glucose control. About 40% of patients with acute ischemic stroke have hyperglycemia. Previous studies have linked hyperglycemia with worse outcomes, including increased infarct growth and higher rates of hemorrhagic transformation. Whether aggressive treatment of hyperglycemia improves outcomes following ischemic stroke is unclear; the SHINE study group conducted a multicenter U.S. trial to investigate. Over a 6-year period, 1151 subjects with acute stroke of less than 12 hours’ duration and hyperglycemia (defined as glucose levels of >110 mg/dL for patients with diabetes and >150 mg/dL for patients without diabetes) were recruited. Mean age was 66 years; 46% were women; median NIH stroke scale score was 7; 63% of subjects received alteplase treatment. Patients were randomized to intensive glucose control with intravenous insulin therapy (target, 80–30 mg/dL) or standard glucose treatment with subcutaneous insulin injections (target, 80–179 mg/dL); treatment was provided for up to 72 hours. During treatment, mean blood glucose was 118 mg/dL in the intensive group and 179 mg/dL in the standard group. The primary outcome — favorable modified Rankin score at 90 days, adjusted for baseline stroke severity — was seen in 20.5% of the intensive treatment group and 21.6% of the standard therapy group (P=0.55). Hypoglycemia or other adverse events requiring cessation of treatment were seen in 11.2% of the intensive group and 3.2% of the standard group. |
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This clinical trial does not provide support for aggressive treatment of hyperglycemia in the setting of acute ischemic stroke. The current American Heart Association/American Stroke Association guideline (NEJM JW Neurol Apr 2018 and Stroke 2018; 49:e46) recommending a glucose target of 140–180 mg/dL for acute stroke patients appears reasonable.