DIABETIC FOOT – CONTEMPORARY INSIGHTS AND EVIDENCE BASED

PERSPECTIVES: UPDATE 2013

Navneet Wadhwa*, Rajiv Parekh**

* Deputy General Manager, Medical Services, Alkem Laboratories Limited, Mumbai **Chief, Division Of Peripheral Vascular And Endovascular Sciences, Medanta – The Medicity Hospital Gurgaon

BACKGROUND

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Diabetic Foot (DF) is a major complication of long standing diabetes, secondary to 1microangiopathy, microangiopathy and neuropathy.

2, 3Foot ulceration is common, affecting up to 25% of patients with diabetes during their lifetime.

Diabetic foot ulceration (DFU) is associated with high morbidity and mortality

Worldwide 1 million amputations are performed each year as a consequence of diabetes; in 490% cases sensory neuropathy is the part of the problem

5Disease Burden

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7Epidemiology – Indian Scenario

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DF accounts for nearly 35% of all hospital admissions in diabetic clinics

DF is responsible for nearly 80 % of all non-traumatic amputations of the lower limbs.

DF absorbs some 20% of the total health-care costs of the disease more than all other diabetic 6complication

In India prevalence of foot ulcers in diabetic patients in clinic population is 3%

This is much lower than the western population due to younger age and shorter duration of diabetes

In India, 55% of foot ulcers are Neuropathic, 35% are neuroischaemic & 10% are Ischaemic

OBJECTIVE

< To conduct a comprehensive overview of recent advances and evidences which would have important impact to improve the management of diabetic foot

With an increase in the prevalence of diabetes the incidence of diabetic complications including diabetic foot is also on rise

METHODS

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Electronic databases (Medline, Pubmed) were searched

The literature published from August 2012 till July 2013 was included in the review

The search criteria included – “diabetic foot”, “diabetic ulceration”, “complications of diabetes”, “amputation of limbs in diabetics”

Peer reviewed case studies, observational studies, case control and cohort studies using the specific MeSH and text ‘Diabetic Foot’ were also included.

Bibliographies of retrieved papers for additional references were hand searched and included for analysis

RESULTS

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A total of 611 papers published during last 1 year were analyzed

26 clinical trials have been published, of which 13 have been conducted under randomized controlled setting.

30 case reports, 5 meta analysis, 3 consensus statement and practice guidelines and 49 review articles have been published.

22 papers from India have been published of which 2 have been clinical trials

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Clinical trials Case Reports Meta analysis- CSPG Review Articles

DISCUSSION9Risk Factors

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Diabetic foot generally occur secondary to diabetic neuropathy

Neuropathy occurs either singly or is associated with Peripheral arterial disease (PAD)

PAD presents in half of patients with DFU, is an independent predictor of limb loss and can be 8

difficult to diagnose in a diabetic population

Summary Points

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Due to an unclear etiology, the treatment options for diabetic wounds are far from satisfactory.

However, recent advances have provided newer understandings to manage diabetic wounds.

Evidence for the better understanding of the diabetic wound healing process, epidemiological trends, prevention, medical, surgical management, is rapidly evolving.

Interesting approaches like clinical application of autologous mesenchymal stem cells, near- infrared spectroscopy prediction of healing, interventions to reduce the oxidative stress are being evaluated from higher level of evidence.

Meta-analysis reveals that treatment with hyperbaric oxygenation improved the rate of healing and reduced the risk of major amputations in patients with diabetic foot ulcers

There is an emerging evidence for aberrant epigenetic mechanisms in diabetic foot ulcers

There is a need for a comprehensive foot care model.

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Clinical Trials RCT

Clinical studies under review

RCT- Randomized Clinical Trial

Published strength of evidence

Total = 93

CSPG: Consensus statement and practice guidelines

Total Studies

Clinical TrialsN=22 N=2

Indian studies

CONCLUSION

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Significant gaps exists for novel approaches to emerge from the bench to bedside, with most of the current studies are still under evaluation and limited to experimental conditions.

There is room for improvement in secondary preventative measures for diabetic foot infections.

Educational campaigns may be beneficial to educate diabetics on the dangers of walking barefoot, the importance of appropriate footwear, regular foot inspection, and the importance of seeking immediate medical attention instead of experimenting with home remedies.

REFERENCES1. Schlienger JL. Type 2 diabetes complications Presse Med. 2013 May;42(5):839-48.

2. NICE Guidelines - http://www.nice.org.uk/nicemedia/live/13416/53557/53557.pdf Accessed on 03- Sep-2013

3. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcer in patients with diabetes. JAMA 2005;293:217-228

4. http://www.diabetes.org/diabetes-basics/diabetes-statistics Accessed on 03- Sep-2013

5. Gupta SK, Singh SK. Diabetic foot: a continuing challenge. Adv Exp Med Biol. 2012;771:123-38.

6. Williams R, Airey M. The size of the problem: economic aspect of foot problems in diabetes. In: Boulton AJM, Connor H, Cavanagh PR, eds. The Foot in Diabetes, 3rd edn. Chichester: Wiley, 2000:3-17

7. http://www.apiindia.org/pdf/medicine_update_2012/diabetology_10.pdf Accessed on 03- Sep-2013

8. Brownrigg JR, Apelqvist J, Bakker K, Schaper NC, Hinchliffe RJ. Evidence-based management of PAD & the diabetic foot. Eur J Vasc Endovasc Surg. 2013 Jun;45(6):673-81.

9. Bortoletto MS, Andrade SM, Matsuo T, Haddad MD, González AD, Silva AM. Risk factors for foot ulcers-A cross sectional survey from a primary care setting in Brazil. Prim Care Diabetes. 2013 Apr 29.