Exenatide in acute ischemic stroke Dear Editor Poststroke hyperglycemia is associated with worse outcome, but trials using intravenous insulin have shown inconsis- tent results (1). Exenatide, a synthetic glucagon-like peptide-1 receptor (GLP- 1R) agonist, reduces blood glucose with- out causing hypoglycemia (2). Moreover, in vitro and animal studies indicate that it may have a neuroprotective action (3). Eleven patients (eight males, three females, median age 80 years, 49–84 years, two with history of diabetes, eight re- ceived tissue plasminogen activator) were recruited prospectively in a nonrandom- ized pilot study between 2010 and 2011. Exenatide, five-micrograms, was adminis- tered subcutaneously within 12 h of ischemic stroke onset and then twice daily for the duration of their hospital stay. Adverse events and finger-prick glucose levels were assessed during the hospital stay, followed by a three-month modified Rankin Scale. Exenatide was started at a median time of nine-hours (4.17–11.5 h) after stroke onset and was continued for a median duration of six-days (one-eight days). There were no serious adverse events or deaths related to exenatide. Mild nausea (n = 6) and vomiting (n = 5) were common adverse events but were always successfully controlled within the first 24 h of starting antiemetics and did not lead to any other complications. There was no symptomatic hypoglycemia and the rate of hyperglycemia (defined as 8.6 mmol/l) was low (4.9%) (Fig. 1). This is the first study of a GLP-1R agonist in human acute stroke patients. Exenatide, when administered with prompt antiemetic therapy, was safe and tolerable in acute ischemic stroke patients and did not worsen any patient’s neuro- logical or functional outcome. We recom- mend prophylactic antiemetic therapy when exenatide is given in the setting of acute stroke. Further trials are indicated to confirm the effectiveness of exenatide in controlling poststroke hyperglycemia. Samantha C. Daly 1,2 , Thomas Chemmanam 3 *, Poh-Sien Loh 3 , Amanda Gilligan 3 , Anthony E. Dear 2,4 , Richard W. Simpson 5 , and Christopher F. Bladin 2,3 1 Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic., Australia 2 Eastern Health Clinical School, Melbourne, Vic., Australia 3 Department of Neurosciences, Eastern Health, Monash University, Melbourne, Vic., Australia 4 Eastern Clinical Research Unit, Biotechnology Division, Monash University, Melbourne, Vic., Australia 5 Department of Diabetes and Endocrinology, Eastern Health, Monash University, Melbourne, Vic., Australia References 1 Gray CS, Hildreth AJ, Sandercock PA et al. Glucose-potassium-insulin infusions in the management of post-stroke hyperglycaemia: the UK Glucose Insulin in Stroke Trial (GIST-UK). Lancet Neurol 2007; 6:397–406. 2 Drucker DJ, Nauck MA. The incretin system: glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors in type 2 diabetes. Lancet 2006; 368:1696–705. 3 Teramoto S, Miyamoto N, Yatomi K et al. Exendin-4, a glucagon-like peptide-1 recep- tor agonist, provides neuroprotection in mice transient focal cerebral ischemia. J Cereb Blood Flow Metab 2011; 31:1696–705. Correspondence: Thomas Chemmanam*, Level 2, 5 Arnold St, Box Hill, Vic. 3128, Australia. E-mail: thomas.chemmanam@easternhealth. org.au DOI: 10.1111/ijs.12073 Fig. 1 Finger-prick glucose levels during exenatide treatment. Finger-prick capillary glucose levels from admission (prior to first dose of exenatide) to day 6. Horizontal lines show threshold for hyperglycemia (8.6 mmol/l) and hypoglycemia (4 mmol/l). Letter to the editor © 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization E44 Vol 8, October 2013, E44