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By Jordana Bieze Foster

Essential to achieving the goal of prevent­ing amputation in patients with diabetes is recognizing barriers that stand in the way, according to a Swedish diabetic foot expert who spoke in March at the Diabetic Foot Global Conference (DFCon) in Los Angeles.

Barriers include vascular compromise and infection, both of which can easily be overlooked in patients with diabetic neuropathy because the classic symptom of pain is absent, said Jan Apelqvist, MD, PhD, senior consultant in the Department of Endocrinology at Skane University Hospital in Malmö, Sweden.

“Patients are actually very rational,” Apelqvist said. “They feel that if there is no pain, there is no problem. They don’t like to change, so they try to avoid the problem for as long as possible.”

He cited multiple studies suggesting a clear shift in the diabetic patient population, formerly characterized primarily by neuropathic foot ulcers but now more often by ulcers in feet that are not just neuropathic but also affected by varying degrees of limited vascular perfusion.

In the EURODIALE (European Study Group on Diabetes and the Lower Extremity) database, about half of the study population of more than 1000 patients with new diabetic foot ulcers also had peripheral arterial disease (PAD). A 2008 Diabetologia study based on EURODIALE data found healing rates were significantly lower in patients with PAD than those without, and that different factors predicted healing in the two groups. A 2009 Diabetologia study of 2511 patients from Apelqvist’s group found similar discrepancies in healing between neuropathic and neuroischemic ulcers.

“We have been so focused on classic clinical signs that we forget the risk related to perfusion,” Apelqvist said.

This means patients who could benefit from revascularization too often are not receiving it in a timely manner, he said. Research, including a 2011 Journal of Vascular Surgery study from the Malmö group, suggests percutaneous transluminal angioplasty and reconstructive vascular surgery significantly increase odds of diabetic foot ulcer healing without amputation.

“We know we have to go in much earlier,” Apelqvist said.

New guidelines from The International Working Group on the Diabetic Foot, published in the February issue of Diabetes Metabolism Research and Reviews, specifically address diagnosis and treatment of PAD in patients with diabetic foot ulcerations.

Similar challenges arise when neuropathic ulcers are complicated by infection: Timely intervention is critical, but diagnosis is often delayed because of the absence of pain.

“If you have a deep infection, you have to do surgery right away or you will lose the foot,” Apelqvist said.

In the EURODIALE database, 58% of patients with diabetic foot ulcers also presented with infection. Infection was a significant predictor of nonhealing in EURODIALE patients with PAD only, but, in a 2011 Diabetes Medicine study, was found to be a predictor of minor amputation in the larger EURODIALE cohort.

Upon realizing that 90% of patients with deep foot infections were already being treated with antibiotics, Apelqvist’s group instituted a structured antibiotic program. Under the new strategy, 10% of patients with deep infections have undergone major amputation and 86% required surgery to achieve healing. Meanwhile, economic costs of treatment have decreased by 28%.

Ultimately, Apelqvist said, the barriers to amputation prevention come down to a failure to consider the whole patient.

“Usually we start with one treatment, and we don’t develop a systematic understanding of the patient in terms of a multi­organ disease,” he said. “What we need to do to save the patient is coordinate all of our efforts into one package.”

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 arterial disease. The EURODIALE study. Diabetologia 2008;51(5):747-755.

Gershater MA, Londahl 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.

Schaper NC, Andros G, Apelqvist J, et al. Specific guidelines for the diagnosis and treatment of peripheral arterial disease in a patient with diabetes and ulceration of the foot 2011. Diabetes Metab Res Rev 2012;28(Suppl 1):236-237.

Van Battum P, Schaper N, Prompers L, et al. Differences in minor amputation rate in diabetic foot disease throughout Europe are in part explained by differences in disease severity at pre­sentation. Diabet Med 2011;28(2):199-205.

A national strategy of risk stratification in Scotland significantly decreased the incidence of amputation within the first years of its implementation, according to unpublished data presented in March at the Diabetic Foot Global Conference (DFCon) in Los Angeles.

Amputation incidence per 1000 patients with diabetes fell by 29.8% from 2004 to 2008, according to Graham P. Leese, MD, chairman of the Scottish Diabetes Foot Action Group. A diabetes foot action plan, which aims to eventually identify the risk of foot ulceration for every patient with diabetes, was first implemented in 2006.

Amputation prevalence has also decreased since implementation of the action plan, from 0.8% in 2003 to 0.5% in 2009, according to the 2009 Scottish Diabetes Survey. Interestingly, duration of diabetes has actually increased slightly even as amputation rates have decreased, indicating that patients are living longer with the disease, Leese said.

Currently more than 248,000 patients with diabetes have been screened, and 86% have been risk stratified, Leese said. By comparison, only 25% of patients with diabetes were risk stratified in 2007.

Source:
Leese GP, Stang D, McKnight JA, et al. A national strategic approach to diabetic foot disease in Scotland: changing a culture. Br J Diab Vasc Dis 2011;11(2):69-73.

Participation in a support group for diabetic amputees is associated with significant clinical and educational benefits, according to unpublished data from the University of Texas Health Sciences Center San Antonio presented in March at the Diabetic Foot Global Conference (DFCon).

As part of a pilot study, researchers compared 15 amputees who participated in a support group and 15 matched amputees who did not. The group met once a month for one to two hours.

After 45 months, support group participants had significantly lower hemoglobin A1C levels and significantly greater understanding of the disease than those who were not group members, according to John Steinberg, DPM, an associate professor of plastic surgery at Georgetown University who was a fellow at UTHSC at the time of the study.

“A support group is an easy thing to do. It takes a room and an idea and a few people to start,” Steinberg said. “We struggled for years thinking it would be too hard, but I don’t give those excuses any credit. Just do it.”

Gary W. Gibbons, MD, chief of vascular surgery at Boston Medical Center, agreed.

“A support group makes people feel better about themselves, so they’re more likely to do better with a lot of the things we ask them to do,” Gibbons said.