New Comprehensive Guidelines Tackle Diabetic Foot Management

Miriam E Tucker

February 15, 2016

New evidence-based clinical-practice guidelines on diabetic foot management cover five areas: ulcer prevention, off-loading, osteomyelitis diagnosis, wound care, and peripheral arterial disease.

This is the first diabetic foot guideline developed by a multidisciplinary panel, which conducted separate systematic literature reviews for each of the five topics.

The document, sponsored jointly by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine, was published as a supplement to the February issue of the Journal of Vascular Surgery by Anil Hingorani, MD, of New York University Lutheran Medical Center, Brooklyn, and colleagues.

"The reality is there's not a lot of really good level 1 evidence for treating these ulcers. That's why we had three different specialties who are all involved in caring for these patients to put their heads together and [determine] what's the best evidence we have to take care of this very difficult problem," Dr Hingorani told Medscape Medical News.

Asked to comment, endocrinologist and diabetic foot expert Jan S Ulbrecht, MD, of Pennsylvania State University, State College, told Medscape Medical News, "I think it's a hugely ambitious and comprehensive document, from a very distinguished group of authors."

Dr Ulbrecht added that although he takes issue with a few specific points, "There can be no doubt that if all care followed these guidelines, diabetic foot disease would be markedly diminished."

Five Recommendations: Examine Feet at Every Visit

The panel issued five recommendations for the care of the diabetic foot.

1. For prevention of foot ulceration, the panel advises adequate glycemic control, periodic foot inspection, and patient and family education. For high-risk patients, including those with significant neuropathy, foot deformities, or previous amputation, custom therapeutic footwear is recommended.

Patients with diabetes should have their feet examined at every visit, Dr Hingorani said, "because it's such a devastating problem. If you can get it when it's small, it's a much smaller problem."

Use of the old standby Semmes-Weinstein monofilament is still considered standard as a screening tool, he noted.

However, Dr Ulbrecht cautioned against spending time on patient education for those in whom no problems are detected with the monofilament, noting that there is no evidence that such efforts provide benefit and may instead cause unnecessary worry.

"In fact, I tell patients with good sensation and not obviously very poor circulation to do as anyone else would. They do not need to add the burden of paying special attention to their feet to all the other burdens of diabetes."

2. In patients with plantar diabetic foot ulcer, the panel recommends off-loading with a total contact cast or irremovable fixed-ankle walking boot. For those with nonplantar wounds or healed ulcers, specific types of pressure-relieving footwear are recommended.

"The evidence for total contact casting for diabetic foot wounds is very, very strong. One of the most important recommendations is off-loading and it's one of the least utilized," Dr Hingorani noted.

Dr Ulbrecht, who has done research on off-loading, wholeheartedly agrees.

3. In patients with a new diabetic foot ulcer, the recommendation is a probe-to-bone test and plain films, followed by MRI if a soft-tissue abscess or osteomyelitis is still suspected following the probe-to-bone test.

Dr Hingorani said that there has been too much reliance on bone scans and that after probing the bone, examining the wound, and simple X ray, "the MRI is the most sensitive, specific, and accurate test.…It is more expensive, but if you're spending a lot of money on tests that aren't accurate you're not getting the diagnosis."

4. Debridement is recommended for all infected ulcers, with treatment of those infections based on the 2012 guidelines published by the Infectious Diseases Society of America. The current document provides detailed recommendations on comprehensive wound care and various debridement methods.

For ulcers that don't improve by more than 50% after 4 weeks of standard wound therapy, adjunctive options are advised. The document lists several, including negative pressure therapy, various biologics, and hyperbaric oxygen therapy.

Dr Hingorani said, "There are hundreds of agents out there. We tried to establish some guidelines but couldn't go over everything. There are no head-to-head comparisons.…But the bottom line is if the wound's not responding, you need to try a different treatment."

5. The panel recommends measurement of ankle-brachial index (ABI) in all patients with diabetes starting at age 50. Those at high risk by virtue of foot ulcer history, prior abnormal vascular exam, or intervention for vascular disease or known cardiovascular disease should have an annual vascular examination of the lower extremities and feet.

In patients with foot ulcer who have peripheral arterial disease, the panel recommends revascularization by either surgical bypass or endovascular therapy.

Dr Ulbrecht took issue with the universal ABI recommendation, noting that, while inexpensive, it does take time and doesn't change management.

"I would argue there's very little you do differently. Some experts say that once you diagnose vascular disease you should be more aggressive about telling patients not to smoke, to lower their cholesterol and blood pressure, etc. But you're doing that anyway."

But despite the small areas of disagreement, Dr Ulbrecht emphasized that he found "nothing egregious" in the guidelines. "This is a consensus of a bunch of people, and mine is a single opinion….Basically, it's a very impressive document, and I fundamentally think it's a big contribution."

Indeed, Dr Hingorani said, "Diabetic foot ulcer is a multidisciplinary problem, and these guidelines really do highlight that.

"It's the first time bringing multiple disciplines together to look at this problem and tackle it," he noted, adding that the panel expects to revise and update it as new information becomes available.

Dr Hingorani and the other panel members have no relevant financial relationships. Dr Ulbrecht is a part owner of DIApedia, an R&D company that has developed off-loading orthoses for at-risk diabetes patients.

J Vasc Surg. 2016;63(suppl):3S–21S. Article


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