Vriesendorp T M, Roos Y B, Kruyt N D, Biessels G J, Kappelle L J, Vermeulen M, Holleman F, DeVries J H, Hoekstra J B L
Department of Internal Medicine, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
J Neurol Neurosurg Psychiatry. 2009 Sep;80(9):1040-3. doi: 10.1136/jnnp.2008.144873.
In patients with acute ischaemic stroke and hyperglycaemia, prolonged strict glycaemic control may improve clinical outcome. The question is how to achieve this prolonged strict glycaemic control. In this study, the efficacy and safety of two regimens with different basal to meal related insulin ratio are described.
33 patients with ischaemic stroke and hyperglycaemia at admission were randomised in an open design to receive: (1) conventional glucose lowering therapy, (2) strict glucose control with predominantly basal insulin using intravenous insulin or (3) strict glucose control with predominantly meal related insulin using subcutaneous insulin in the first 5 days after stroke. The target range of glucose control for the last two groups was 4.4-6.1 mmol/l. 16 consecutive patients without hyperglycaemia at admission were included to serve as normoglycaemic controls.
The median area under the curve (AUC) in the meal related insulin group was 386 mmol/l x 58 h (range 286-662) for days 2-5, and did not differ from the hyperglycaemic control group (median AUC 444 mmol/l x 58 h; range 388-620). There was also no difference in median AUC of the basal insulin group (453 mmol/l x 58 h, range 347-629) and the hyperglycaemic control group on days 2-5. In the first 12 hours, glucose profiles were lower in the groups treated with strict glucose control; median AUC was 90 mmol/l x 12 h (range 77-189) for the hyperglycaemic control group versus 81 mmol/l x 12 h (range 60-118) for the meal related insulin group (p = 0.03) and 74 mmol/l x 12 h (range 52-97) for the basal insulin group (p = 0.008).
In intermittently fed ischaemic stroke patients, strict glycaemic control between day 2 and day 5 with two different basal bolus regimens did not result in lower glucose profiles due to postprandial hyperglycaemia. Continuous enteral feeding may therefore be needed to achieve prolonged strict glycaemic control in acute stroke patients.
在急性缺血性中风和高血糖患者中，延长严格的血糖控制可能会改善临床结局。问题在于如何实现这种延长的严格血糖控制。在本研究中，描述了两种基础胰岛素与餐时胰岛素比例不同的治疗方案的疗效和安全性。
33例入院时患有缺血性中风和高血糖的患者采用开放设计随机分组，接受：（1）传统降糖治疗，（2）在中风后的前5天使用静脉胰岛素以基础胰岛素为主进行严格血糖控制，或（3）使用皮下胰岛素以餐时胰岛素为主进行严格血糖控制。后两组的血糖控制目标范围为4.4 - 6.1 mmol/L。纳入16例入院时无高血糖的连续患者作为正常血糖对照组。
餐时胰岛素组第2 - 5天曲线下面积（AUC）中位数为386 mmol/L×58小时（范围286 - 662），与高血糖对照组无差异（AUC中位数444 mmol/L×58小时；范围388 - 620）。基础胰岛素组第2 - 5天的AUC中位数（453 mmol/L×58小时，范围347 - 629）与高血糖对照组也无差异。在最初12小时内，严格血糖控制组的血糖曲线较低；高血糖对照组的AUC中位数为90 mmol/L×12小时（范围77 - 189），餐时胰岛素组为81 mmol/L×12小时（范围60 - 118）（p = 0.03），基础胰岛素组为74 mmol/L×12小时（范围52 - 97）（p = 0.008）。
在间歇性喂食的缺血性中风患者中，在第2天至第5天使用两种不同的基础 - 大剂量方案进行严格血糖控制，并未因餐后高血糖而导致更低的血糖曲线。因此，可能需要持续肠内喂养以在急性中风患者中实现延长的严格血糖控制。
