ABSTRACT
Background and aims: Hyperglycaemia in acute ischaemic stroke (AIS) is common, reduces the efficacy of stroke thrombolysis and thrombectomy, with worse clinical outcomes. Insulin therapies are difficult to implement and maintain, and may cause symptomatic hypoglycaemia. An alternative treatment is Exenatide, a GLP-1 agonist that lowers blood glucose with a very low risk of hypoglycaemia. Methods: The Trial of Exenatide in Acute Ischaemic Stroke (TEXAIS) enrolled adult patients with AIS ≤9 hours of stroke onset to receive treatment with short-acting Exenatide (5μg bid subcutaneous injection) or Standard care for 5 days, or until hospital discharge (whichever sooner).Primary outcome: proportion of patients with ≥8 point improvement in NIHSS score (or NIHSS 0-1) at 7 days. Results: 350 patients randomised, median age 71 years (IQR 62, 79), and median NIHSS 4 (IQR 2, 8). Planned recruitment (n=528) stopped early due to Covid and time constraints. On Admission the median blood glucose was 6.7 (IQR 5.70, 8.50), and 42% patients had hyperglycaemia (>7.0 mmol/L). Primary outcome occurred in 97/171 (56.7%) in Standard care group vs 104/170 (61.2%) in Exenatide group [aOR: 1.22 (CI 0.79, 1.88) p=0.38]. Mean daily per-patient frequency of hyperglycaemia was significantly less in the Exenatide group (p=0.002). No episodes of hypoglycaemia reported over the treatment period. Nausea/vomiting occurred in 7/174 (4.0%) patients on Exenatide. Conclusions: In this Phase 2 trial Exenatide did not significantly reduce neurological disability at 7 days. Exenatide significantly reduced frequency of hyperglycaemic events, and was safe to use. These results warrant further investigation with larger Phase 3 trials.
ABSTRACT
Background and aims: National clinical quality registries facilitate reliable monitoring of stroke care by providing local hospital teams with data on their performance compared to national benchmarks. We aimed to assess changes in stroke care over time from public hospitals participating in the Australian Stroke Clinical Registry (AuSCR). Methods: AuSCR stroke quality care indicators were compared between 2017 and 2020, using a matched-hospital design. Analyses were limited to adults with stroke or transient ischaemic attack admitted to hospitals contributing ≥30 episodes each year during the study period. Descriptive statistics and linear tests for trend were used to assess changes in quality indicators across years. Results: Among 47 eligible hospitals, admissions increased from 13,508 (2017) to 18,139 (2020). Overall, half were aged ≥75 years, 45% were female, and 59% had a severe stroke (no differences by year). Between 2017 and 2020, improvements were observed for: endovascular retrieval (+8%;P<0.001), hyperacute antithrombotics (+6%;P<0.001), mobilisation during admission (+3%;P<0.001), swallow screen/assessment within 4 hours (+12%;P<0.001), discharge care planning (+11%;P<0.001), and discharge secondary prevention medications (+10%;P<0.001). However, delivery of thrombolysis remained unchanged (-1%;P=0.07), door-toneedle within 60 minutes decreased (-6%;P=0.008), and access to stroke unit care declined in 2020 (76% 2019 vs 72% 2020;P<0.001). Conclusion: Improvements in many indicators of quality stroke care have been observed within Australian hospitals participating in a national registry. Declines in timeliness to thrombolysis and access to stroke units in 2020 represent a likely consequence of the COVID-19 pandemic that requires national action.