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.
No comments:
Post a Comment