Most treatment for diabetic foot ulcers focuses on repairing surrounding tissue and healing the wound, but a new study says that’s the wrong approach. Instead doctors should concentrate on remission—that is, extending the time between ulcer formation.
As many as one-third of people with diabetes will develop a foot ulcer, which can lead to complications such as strokes, heart attacks, infections, loss of limbs, and even premature death.
Extending patients’ ulcer-free days using treatment and prevention is essential, says David Armstrong, professor of surgery and director of the Southern Arizona Limb Salvage Alliance at the University of Arizona College of Medicine-Tucson, and author of a new study in the New England Journal of Medicine.
“This paper is the first of its kind to call attention to remission. The word ‘remission’ has been mentioned in the literature over the last few years. But this is the loudest call yet, and more than any other work before, [it] lays out data in a way that sort of flips the script from healing to what we do in between healed wounds.”
People with foot ulcers may have a lessened ability to feel pain coupled with repetitive stress on specific areas of the foot. Once healed, as many as 40 percent of patients will have recurrence of some kind in a year. This rises to three-quarters of patients by five years.
Morbidity and mortality associated with diabetes is like cancer, Armstrong says. But clinicians have yet to treat them the same.
“The real idea here is…to help people move through their world a little better and give them more ulcer-free days and more activity-rich days.”
“Diabetes can be more significant than many forms of cancer. This is a concept that’s misaligned right now in medicine. As we move toward diseases of decay, as I call them—things like cancer, cardiovascular disease, diabetes—our goal as physicians, surgeons, scientists, and policymakers is to delay that decay.”
Diabetes is unique because people can unknowingly injure themselves. “People can wear a hole in their foot just as you or I might wear a hole in a sock,” Armstrong says. “These sores are covered up by a shoe or a sock, and very often a person with diabetes may feel little or no pain.”
But developing a diabetic foot ulcer means the chance of living an additional 10 years are half that of someone who hasn’t developed one. What’s more, foot ulcers and infections dramatically increase a person’s chances of being admitted to the hospital.
“We looked at the data from 5 billion outpatient visits and found that diabetic foot ulcers and diabetic foot infections were astonishingly high-risk factors for hospitalization,” Armstrong says. The admission rate is comparable to, or exceeds that of congestive heart failure, kidney disease, depression, and most types of cancer.
To realign the way in which diabetes is viewed and treated, physicians must begin talking with their patients about severe complications, the way they talk with their patients about cancer, and emphasize that with new technologies and continuous care, such as careful dosing of physical activity, remission can be prolonged.
“The real idea here is for physicians to help people move through their world a little better and give them more ulcer-free days and more activity-rich days,” Armstrong says. “We want to keep our patients moving, so they’re not on the sidelines of life.”
Researchers from the University of Manchester and the University of Amsterdam are coauthors of the study.
Source: University of Arizona