May 24, 2016

Diabetic Foot, First-Ever Guidelines

The Society for Vascular Surgery, the American Podiatric Medical Association and the Society for Vascular Medicine collaboratively publish first-ever set of clinical practiceguidelines for treating the diabetic foot.

The new guidelines, “The Management of the Diabetic Foot,” were developed after three years of studies and were published online and in print in the Journal for Vascular Surgery.

Since diabetes mellitus continues to grow in global prevalence and to consume an increasing amount of healthcare resources the clinical practice guidelines were developed. One of the key areas of morbidity associated with diabetes is the diabetic foot. The guidelines seek to improve the care of patients with diabetic foot and to provide an evidence-based multidisciplinary management approach.

The committee made specific practice recommendations using the Grades of Recommendation Assessment, Development, and Evaluation system. This was based on five systematic reviews of the literature. Specific areas of focus included (1) prevention of diabetic foot ulceration, (2) off-loading, (3) diagnosis of osteomyelitis, (4) wound care, and (5) peripheral arterial disease.

Although they identified only limited high-quality evidence for many of the critical questions, they used the best available evidence and considered the patients’ values and preferences and the clinical context to develop these guidelines. They include preventive recommendations such as those for adequate glycemic control, periodic foot inspection, and patient and family education. They recommend using custom therapeutic footwear in high-risk diabetic patients, including those with significant neuropathy, foot deformities, or previous amputation. In patients with plantar diabetic foot ulcer (DFU), they recommend off-loading with a total contact cast or irremovable fixed ankle-walking boot. In patients with a new DFU, they recommend probe to bone test and plain films to be followed by magnetic resonance imaging if a soft tissue abscess or osteomyelitis is suspected. They provide recommendations on comprehensive wound care and various debridement methods. For DFUs that fail to improve (Less than 50% wound area reduction) after a minimum of 4 weeks of standard wound therapy, we recommend adjunctive wound therapy options. In patients with DFU who have peripheral arterial disease, they recommend revascularization by either surgical bypass or endovascular therapy.

Whereas these guidelines have addressed five key areas in the care of DFUs, they do not cover all the aspects of this complex condition. At least in the future as evidence accumulates, they plan to update recommendations accordingly.

Diabetes is one of the leading causes of chronic disease and limb loss worldwide, currently affecting 382 million people. It is predicted that by 2035, the number of reported diabetes cases would soar to 592 million. This disease affects the developing countries disproportionately as greater than 80% of diabetes deaths occur in low- and middle-income countries.

This progression from foot ulcer to amputation leads to several possible steps where intervention based on evidence-based guidelines may prevent major amputation. Considering the disease burden and the existing variations in care that make decision-making very challenging for patients and clinicians, the SVS, American Podiatric Medical Association, and Society for Vascular Medicine deemed the management of DFU a priority topic for clinical practice guideline development. These recommendations are meant to pertain to all people with diabetes regardless of etiology.

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