| Reworded | The prognosis of persistent hyperglycaemia in patients with AIS within 24 hours after onset is worse than that of normal blood glucose. Therefore, it is reasonable to treat hyperglycaemia by aiming for target blood glucose levels between 140 and 180 mg/dL (7.8–10.0 mmol/L), while closely monitoring to prevent hypoglycaemia. | IIa | C |
| Reworded | Hypoglycaemia (<60 mg/dL or 3.3 mmol/L) should be promptly corrected in patients with ischaemic cerebrovascular disease. | I | C |
| New recommendation | Diabetes, pre-diabetes and insulin resistance are independent risk factors for recurrent IS or death. Screening for the glucose metabolism status of patients who had a stroke should be emphasised. | IIa | B |
| Multiple studies have found a correlation between pre-diabetes, insulin resistance, diabetes, and adverse outcomes such as the occurrence, recurrence, and mortality of IS.254–257 However, during the acute phase of stroke, there is a phenomenon of underdiagnosis for newly developed diabetes or pre-diabetes, which suggests that clinicians should prioritise screening for diabetes, pre-diabetes and insulin resistance in patients with IS or TIA.258
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| New recommendation | For patients who had an IS or TIA with concomitant diabetes, the target for blood glucose control in the post-acute phase should be individualised. The effect of strict blood glucose control (eg, HbA1c ≤7%) on preventing stroke recurrence remains uncertain. | IIb | B |
| Several international clinical trials have failed to demonstrate that intensified glycaemic control reduces the risk of macrovascular diseases or lowers the risk of all-cause mortality or stroke.259–261 Instead, there is a significant increase in the risk of severe hypoglycaemia. The ADVANCE study found that strict blood glucose control, aiming for HbA1c <6.5%, significantly reduces the occurrence of composite endpoints, including vascular events.262 Therefore, the overall recommendation is to target the level of HbA1c to ≤7%, but individualised adjustments should be made. |
| Reworded | Individualised blood glucose control targets should be established. Hypoglycaemic events should be noted. | IIa | B |
| New recommendation | For patients who had an IS or TIA with pre-diabetes, lifestyle interventions such as a healthy diet, regular physical activity and smoking cessation are beneficial in preventing the progression of diabetes. | IIa | B |
| Lifestyle intervention has emerged as a safe and effective approach to impede the progression of pre-diabetes toward diabetes. The Da Qing Diabetes Prevention Study, which followed participants for a period of 23 years, revealed that lifestyle intervention for patients with impaired glucose tolerance can significantly reduce the long-term risk of diabetes, cardiovascular events and mortality.263
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| New recommendation | Metformin may be beneficial in preventing the progression of diabetes. | IIa | B |
| The DPP study demonstrated the efficacy of both intensive lifestyle intervention and metformin in mitigating the progression from impaired glucose tolerance to diabetes.264 While intensive lifestyle intervention exhibits superior outcomes compared with metformin, it is noteworthy that metformin demonstrates favourable tolerability and cost-effectiveness. |
| New recommendation | For patients who had an IS or TIA with diabetes, a combination of lifestyle interventions, nutritional support, self-management education and antihyperglycaemic medications is advised. | I | C |
| Blood glucose management requires a multifaceted approach, including lifestyle modifications, nutritional support, diabetes self-education and glucose-lowering medications.265 266
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| New recommendation | Newer antihyperglycaemic medications, such as glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors, which have demonstrated beneficial effects in reducing the risk of cardiovascular events, including stroke, MI and vascular mortality, may be considered viable options. | IIa | B |
| The REWIND study included high-risk patients with type 2 diabetes and cardiovascular disease, randomly assigning them to receive either the dulaglutide or placebo. The primary composite endpoints included non-fatal MI, non-fatal stroke or vascular death. The study found a significant reduction in the risk of major composite endpoints with dulaglutide compared with placebo (HR 0.88, 95% CI 0.79 to 0.99).267 The CANVAS study found that the risk of vascular events and mortality in the canagliflozin group was significantly lower than in the placebo group (HR 0.86, 95% CI 0.75 to 0.97).268
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| New recommendation | In patients without diabetes with recent IS or TIA and insulin resistance, after excluding contraindications, the use of pioglitazone may be beneficial in preventing recurrent strokes. | IIa | B |
| In the IRIS trial, conducted among patients without diabetes with recent IS and insulin resistance, pioglitazone demonstrated a 24% reduction in the risk of stroke recurrence or MI compared with placebo (HR 0.76, 95% CI 0.62 to 0.93).269
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