A paradigm shift is needed in diabetic foot care
09/02/10 | Diabetic foot ulcers | Jan Apelqvist
BROADER CLASSICATION REQUIRED TO OPTIMISE CARE
In large cohort studies of patients with diabetes and foot ulcers the outcome has been measured with regard to the possibility of primary healing (healing without amputation) or of avoiding major amputation at or above the ankle [2,13]. In many studies of diabetic patients, usually about 10 to 15% (and sometimes as many as 30%) of patients not considered suitable for vascular surgery have been shown to heal without amputation or without a major amputation [2, 4].
Studies with regard to vascular intervention, on the other hand, have focused on 'limb salvage' and graft survival [6,8,14-17], indicating a need to introduce and recognise decreased perfusion or impaired circulation as an indicator for intervention in the diabetic foot to achieve healing and maintain healing and to avoid or delay a future amputation [1,2,5,13,18-20].
A new classification system is needed that recognises the various degrees of disturbed perfusion to better match appropriate treatment to individual patients – whether that be reconstructive, endovascular or pharmacological – alone or in combination.
These findings indicate a need for the recognition that a new approach and classification in neuroischaemic diabetic individuals is required, both with regard to clinical practice and science/research. New strategies must be developed and implemented for patients with a diabetic foot with decreased perfusion to improve healing, healing rate and to avoid amputation, irrespective of the intervention technology chosen. Clinicians must also recognise that a diagnosis of neuroischaemia is not only based on the presence of obstructive vascular disease.
Jan Apelqvist, MD, PhD, Associate Professor for Diabetes and Endocrinology, University Hospital Malmo, University of Lund, Malmo, Sweden
- Prompers L, Huijberts M, Apelqvist J, et al. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia 2007; 50(1): 18-25.
- Gershater MA, Löndahl M, Nyberg P, et al. Complexity of factors related to outcome of neuropathic and neuroischaemic/ischaemic diabetic foot ulcers: a cohort study. Diabetologia 2009; 52(3): 398-407.
- Apelqvist J, Bakker K, Houtum WH, et al. International Working Group on the Diabetic Foot (IWGDF) Editorial Board. Practical guidelines on the management and prevention of the diabetic foot: based upon the International Consensus on the Diabetic Foot (2007). Prepared by the International Working Group on the Diabetic Foot. Diabetes Metab Res Rev 2008; 24(Suppl 1): S181-7.
- International Working Group on the Diabetic Foot. International Consensus on the Diabetic Foot and Practical Guidelines on the Management and the Prevention of the Diabetic Foot. Amsterdam, the Netherlands, 2007; available on CD-ROM at: www.idf.org/bookshop.
- Apelqvist J, Larsson J. What is the most effective way to reduce incidence of amputation in the diabetic foot? Diabetes Metab Res Rev 2000; 16(Suppl 1): S75-83.
- Adam DJ, Beard JD, Cleveland T, et al on behalf of the BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet 2005; 366(9501): 1925-34.
- Schaper NC, Nabuurs-Franssen, MH, Huijberts SP. Peripheral vascular disease and type 2 diabetes mellitus. Diabetes Metab Res Rev 2000; 16(Suppl 1): S11-15.
- Mills JL Open bypass and endoluminal therapy: complementary techniques for revascularisation in diabetic patients with critical limb ischaemia. Diabetes Metab Res Rev 2008; 24(Suppl 1): S34-9.
- Kalani M, Apelqvist J, Blombäck M, et al. Effect of daltiparin on healing of chronic foot ulcers in diabetic patients with peripheral arterial occlusive disease - a prospective, randomized, double-blind, placebo-controlled study. Diabetes Care 2003; 26(9): 2575-80.
- Hinchliffe RJ, Valk GD, Apelqvist J. et al. A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev 2008; 24(Suppl 1): S119-44.
- Rullan M, Cerda, L, Frontera G, et al. Treatment of chronic diabetic foot ulcers with bemiparin: a randomized, triple-blind, placebo-controlled, clinical trial. Diabet Med 2008; 25(9): 1090-5. Erratum in: Diabet Med 2008; 25(10): 1257.
- Weck M, Rietzsch H, Lawall H, et al. Intermittent intravenous urokinase for critical limb ischemia in diabetic foot ulceration. Thromb Haemost 2008; 100(3): 475-82.
- Prompers L, Schaper N, Apelqvist J, et al. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral vascular disease. The EURODIALE study. Diabetologia 2008; 51(5): 747-55.
- Norgren L, Hiatt WR, Dormandy JA, et al on behalf of the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45(Suppl): S5-S67.
- Faglia E, Mantero M, Caminiti M, et al. Extensive use of peripheral angioplasty, particularly infrapopliteal, in the treatment of ischaemic diabetic foot ulcers: clinical results of a multicentric study of 221 consecutive diabetic subjects. J Intern Med 2002; 252(3): 225-32.
- Jacqueminet S, Hartemann-Heurtier A, Izzillo R, et al. Percutaneous transluminal angioplasty in severe diabetic foot ischemia: outcomes and prognostic factors. Diabetes Metab 2005; 31(4 pt 1): 370-5.
- Andros G. Diagnostic and therapeutic arterial interventions in the ulcerated diabetic foot. Diabetes Metab Res Rev 2004; 20(Suppl 1): S29-33.
- Schaper NC. Diabetic foot ulcer classification system for research purposes: a progress report on criteria for including patients in research studies. Diabetes Metab Res Rev 2004; 20(Suppl 1): 90-5.
- Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 1998; 21(5): 855-9.
- Beckert S, Witte M, Wicke C, et al. A new wound-based severity score for diabetic foot ulcers. Diabetes Care 2006; 29(5): 988-92.
- A broader classification that recognises various degrees of disturbed perfusion is needed to better match appropriate treatment to individual patients
- The future focus needs to be on a new approach to management and classification in patients with neuroischaemic diabetic foot ulcers