Three Ts Needed to Treat the Diabetic Foot

Written by Christine Rhodes MS

Lower extremity complications of diabetes are now more expensive than the 5 most expensive cancers in the United States,1 David G. Armstrong, DPM, MD, PhD, told Endocrine Web, after moderating an in-depth symposium, The Diabetic Foot: Clear and Unpleasant Danger, at the American Association of Clinical Endocrinologists (AACE) 26th Annual Scientific and Clinical Congress in Austin, Texas, with Andrew Boulton, MD, DSc, professor of medicine at the University of Manchester in Manchester, England.

“The good news, however, is that with a combination of team, technology, and tenacity, most [foot] ulcers can be mitigated and amputations prevented,” he said. Dr. Armstrong, professor of Surgery at the University of Arizona and Deputy Director of the Arizona Center for Accelerated Biomedical Innovation,

Team Approach to Limb Salvage

From screening and prevention, to wound healing, infection management, and revascularization, the “Toe and Flow” model for the high-risk foot brings together the podiatrist (toe) and vascular surgeon (flow), with support from other key providers, to treat the vascular patient with critical limb ischemia.

Neuropathy, followed by ulceration, vascular impairment, and infection usually lead to a need for amputation in the patient with diabetes,1 said Christian J. Ochoa, MD, Assistant Professor of Clinical Surgery at the Keck School of Medicine at the University of Southern California, speaking at the AACE annual meeting; and successful salvage is possible when a team approach is used so individual team members are able to focus as needed.

“Endocrinologists are key members of the team because they can perform vascular noninvasive studies that provide basic information on blood flow and determine the severity of peripheral arterial disease (PAD),” Dr. Ochoa told EndocrineWeb “When blood flow is decreased or nondetectable, referral to a podiatrist or vascular surgeon is indicated.”

Unfortunately, as many as 50% of PAD patients are asymptomatic, while 40% to 50% of PAD patients present with nonspecific leg complaints.2 Physical examination of the legs is unreliable, leading researchers to recommend noninvasive vascular tests to screen patients for PAD at every exam.2

Dr. Ochoa outlined the noninvasive vascular tests best used for PAD screening by an endocrinologist:1

Diabetes carries a 4-fold increase in risk for PAD compared to the general population,4 according to Dr. Ochoa. When critical limb ischemia is reached, a choice needs to be made between bypass surgery and balloon angioplasty to revascularize the lower extremity and, hopefully, prevent amputation.

Elliot Joslin, MD, pioneered the team approach to diabetes, incorporating foot care, medical and nutritional therapy, exercise, prompt treatment of infection, and specialized surgical care.3 Today, limb preservation teams are credited with reducing major amputations by as much as 95% with improved wound healing, and a low rate of ulcer recurrence.4

Keeping the Diabetic Foot in Remission

“Diabetic foot complications are common, complicated, and costly,” said Dr. Armstrong. The presence of a diabetic foot ulcer often leads to re-ulceration with accompanying increases in healthcare costs. Therefore, keeping the diabetic foot in remission is an important goal for endocrinologists, podiatrists, and vascular surgeons.

“There are a number of supercool new technologies designed to extend the number of ‘ulcer free days’ for the patient in diabetic foot remission,” Dr. Armstrong told EndocrineWeb. He described new home-based and even implantable sensors that are likely to fundamentally change the way patients interact with our doctors and nurses.1

Wounds tend to heat up before they break down, said Dr. Armstrong, so we can provide a home security system for the body that looks like a bathmat, socks that measure foot temperature, shoes that electronically control the pressure applied to the bottom of diabetic feet or a personal inflammation monitor.

“Just as we wish to feel safe in our homes, these systems allow diabetics to feel safe in their bodies,” Dr. Armstrong said. Dr. Armstrong is the founder of SALSA, a collaborative clinical and research alliance based in Arizona that is dedicated to advancing the care of the diabetic foot and preventing amputations in North America and worldwide. With a team of physicians, surgeons, engineers and scientists from 14 nations, SALSA conducts clinical trials and research on the development of intelligent textiles, fall prevention, and exploration and phenotyping of the human microbiome.

Sources

  1. Boulton A, Armstrong D, Ochoa C. Presented: The Diabetic Foot: Clear and Unpleasant Danger at the AACE 26th Clinical and Scientific annual meeting, May 3-7, in Austin, Texas.
  2. Hirsch AT, Haskal ZJ, Hertzer NR et al. ACC/AHA guideline for the management of patients with peripheral arterial disease. J Am Coll Cardiol. 2006;47:1239-1312.
  3. The Joslin Diabetes Center. Elliot P. Joslin. Available at: http://www.joslin.org/about/elliot_p_joslin_md.html. Accessed May 11, 2017.
  4. Khan et al. Does the clinical examination predict lower extremity peripheral arterial disease? JAMA. 2006;295:536-546.