Poststroke hyperglycemia management: more answers required.

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To the Editor: We read with interest the latest article discussing the immediate management of poststroke hyperglycemia.1 Gray and colleagues advocate the use of glucose-potassium-insulin (GKI) infusions to maintain euglycemia within the first 24 hours poststroke, the rationale for this being that plasma glucose level peaks and exerts its harmful effects on the ischemic penumbra within this time period. However, in reality, nonphysiological surges of plasma glucose levels are also likely to occur beyond 24 hours and may be caused by a number of factors including early enteral feeding, use of solutions containing glucose, and secondary complications (eg, sepsis). Therefore, it may be conceivable that the detrimental effects of hyperglycemia persist beyond the first 24 hours of stroke, which Gray and colleagues have not addressed. Indeed, we demonstrated that changes in glycated serum protein levels in the first 2 weeks after stroke were significantly associated with an increase in death and disability at 3 months, after adjusting for stroke severity.2 In vitro studies have suggested that glycated proteins induce proinflammatory cytokines leading to endothelial cell damage and subsequent vascular occlusion.3 The use of intensive insulin therapy in maintaining blood glucose <6.1 mmol/L in critical care patients beyond 24 hours has also been shown to be beneficial in reducing in hospital mortality, sepsis, and renal failure.4 The benefits were seen irrespective of whether patients were rendered hyperglycemic with enteral or …