Treatment of Diabetic Ulcers:

Guiding Principle

The primary treatment goal for diabetic foot ulcers is to

obtain wound closure as expeditiously as possible.

No relevant disclosures

Debbie Christensen RN CWOCN

Manager Wound and Ostomy Department

Sacred Heart Medical Center

dchristensen@peacehealth.org

Office phone 541-222-2560

The urgency to close DFU’s

• 10 year prospective study of patients over 65, a

neuropathic ulcer was predictive for a 45% mortality rate

over 5 years.1

• Three most common factors leading to limb amputation:– Gangrene, infection, non-healing wound4

1. Iversen, Tell, Riise, et al 2009

4. Rogers, L. 2010

Standard Treatment Fails to Heal DFU’s

Standard treatment:

• Wound Bed preparation: Debridement

• Infection Control

• Revascularization

• Off Loading

Only 25% of patients who received this standard

treatment healed by 16 weeks.5,6

5. Steed and colleagues J AM Coll Surg 1996 Multicenter randomized

6. Margolis and colleagues, Diabetes Care 1992 Meta-analysis

• A systematic review of literature revealed that between

30% - 40% of patients were not being treated according

to current evidence.2

• A 2010 consensus panel identified that 20-30% of the

care provided was inappropriate or dangerous.3

2. Schuster and colleagues

3. Snyder, Kirsner and colleagues 2010 Consensus Report

Evidence Based DFU TreatmentGuidelines abound

Association for the Advancement of Wound Care

American College of Foot and Ankle Surgeons

American Diabetes Association

American Orthopedic Foot and Ankle Society

Wound Ostomy Continence Nurses Society

Wound Healing Society

Guidlelines

• Provide a standard framework for assessment and

diagnosis.

• Establish best practice standards for basic wound care

interventions and expected progress.

• Provide guidance for evidence based use of advanced

wound therapies.

• Provide a reference from which to measure outcomes.

Medical Management

Glucose Control: HbA1c. <7%.

Neurologic Testing: Monofilament 5.07

Vascular Assessment

Edema Management: Elevation vs. compression

Nutrition: Diabetic education, Pre-albumin

Social barriers: Living situation, lack of family support, financial

Patient beliefs and motivation: Motivational interviewing8

8. CARL J. POSSIDENTE, and colleagues

Am J Health-Syst Pharm. 2005

Wound Assessment

Measure the wound:

Length x width x depth

Consistency is key to tracking progress

Probe to Bone Controversy8,9

Use appropriate size probe for the wound

Can identify underlying foci of indolent infection in otherwise healthy

appearing wound

Wound tissue and Infection

Healthy tissue is pink with advancing, adherent edge. Friable, dark tissue

with undermined edges is not.

8.Lavery, et al Diabetes Care 2007

9. Grayson and colleagues, JAMA 1995

Basic Standard Wound CareOff load :

If the offloading device can be removed it will be

Caution in use of wheel chairs and crutches9

Debridement

Reduces bacterial bioburden, reduces infection

Converts wound to an active, proliferative state.

Suggested weekly and as needed5

Surgical and Sharp recommended.

Enzyme: Santyl the only one still on market.

Manage /Rule Out Infection

Provide Moist Wound healing

9. Orsted and colleagues, WoundCare 2007

5. Steed and Colleagues Regranex study, numerous other studies

Basic Standard Wound Care: Moist Wound HealingGoals: Maintain a moist wound surface

Minimizes trauma to the wound tissue

Minimize risk of infection

Manage drainage to preserve peri-wound skin.

50% Reduction in wound size at 4 weeks

Dressing selection should be based on choosing the most cost effective dressing

which meets wound needs9

9. Orsted and colleagues, WoundCare 2007

Basic Standard Wound Care: Moist Wound HealingCleanse with noncytotoxic cleansers10

Saline, clean water, wound cleansers, surfactants

Wound gels and pastes:

Amorphous wound gel, Cadexomer Iodine wound paste, Manuka

honey

Wound Fillers:

Gauze, Calcium alginate, collagen

Cover dressings:

Gauze, foam , hydrocolloids, composite dressings, film dressing,

silver impregnated dressings10. WOCN guideline2004

Home or Skilled Care Wound Supplies

• Most Insurers cover primary and secondary dressings.

• Coverage requires a complete prescription

– Wound dimensions, date of assessment, supplies and

frequency of change.

• Limit number of dressing prescribed to accommodate for revised

dressing needs as the wound changes.

• Nursing Facilities and Home Health organizations are on strict

formularies and need wound care orders written in generic terms.

i.e.– Adhesive foam dressing vs. propriatary Allevyn, Hydrasorb , Polymem

– Hydrocolloid

– Calcium alginate

Reassess wounds regularly

• Frequency based on needs of the wound and the patient.

• Failure to achieve 50% reduction in size over 4 weeks indicates

need to reevaluate;

– Patient comorbidities

– Offloading

– Adequacy of debridement and wound care

If goals have been met in these areas consider use of advanced

wound therapies. 3,13,14,

3. Snyder, Kirsner, et al,

13. Bolton, et al N Engl J Med. 2004

14.Sheehan and colleagues, Diabetes Care 2003

Advanced Wound Therapies

It is the basic care which prepares the wound for advanced

therapies. Skip the basics and it will not make a

difference what advanced therapies you use.7

7. Frykberg, Wounds 2010

Advanced Therapies

Negative Pressure Therapy

Kalypto, Svedman, Renasys, VAC

Manage drainage, enhance wound contraction and angiogenasis

Extracellular Matrix products

Oasis, Integra, GRAFTJACKET regenerative tissue matrix,

Provide a scaffold for tissue in growth and cellular migration

Cellular Based Tissue Technologies

Apligraf, Dermagraftt. Both have FDA approval15, 16

Provide growth factors to the wound to stimulate healing

Hyperbarics

Other Advanced Therapies

• Platelet Rich Plasma

• Ultrasonic spray (MIST, Celleration)

• Electrical stimulation

• Super oxidized water ( Dermacyn)

Advanced Wound Therapies

By using a combination of these advanced therapeutic

products based on their supporting clinical science and

evidence we should be able to improve DFU healing.

Advanced Therapies of course come at an advanced cost.

A number have a favorable reimbursement which drives

use.

Remember Bercaplamin….

The Reality of Diabetic Ulcer Healing

At the end you get back:

A diabetic patient,

With a Neuropathic foot,

Who has a very expensive layer of skin over scar tissue.

So what comes next?

Managing ComorbiditiesLifestyle/Psychosocial Factors

Patient Compliance1. Patient Centered Plan of Care

• The wound belongs to the patient and he must be an active participant in the plan to heal it.

2. Motivational interviewing/Motivational Enhancement

• Discovering the barriers the patient perceives and assisting him to discover his own solutions may result in improved compliance.

CARL J. POSSIDENTE, KATHRYN K. BUCCI, AND WALTER J. MCCLAIN

Am J Health-Syst Pharm. 2005

References1. Iversen, Tell, Riise, et al. History of foot ulcer increases mortality among individuals with

diabetes: Norway. Diabetes Care. 2009

2. Schuster, McGlynn, Brook. How good is the quality of care in the United States? Milbank

U1998

3. Snyder, Kirsner, et al; Consensus Recommendations on Advancing the Standard of Care for

Neuropathic foot Ulcer in Patients with Diabetes. 2010

http://www.o-wm.com/files/docs/ABH_WOUNDS.pdf

4. Rogers, L. Key concepts from the 2010 consensus statement. Wounds 2010

5. Steed, Donohoe, Webster. Effect of extensive debridement and treatment on the healing of

diabetic foot ulcers J AM Coll Surg 1996

6. Margolis, Cantor, Berlin. Healing of neuropathic ulcers receiving standard treament: a meta-

analysis. Diabetes Care 1992

7. Frykenberg, Robert G. The science of advanced wound care: What should you be using in

your office. Wounds 2010

8. Lavery, Armstrong, Wunderlich, et al. Risk factors for foot infection in individuals with

diabetes.. Diabetes Care 2007

9. Grayson, Gibbons, Balogh, et al. Probing to bone in infected pedal ulcers. A clinical sign of

underlying osteomyelitis, JAMA 1995

10. CARL J. POSSIDENTE, KATHRYN K. BUCCI, AND WALTER J. MCCLAIN Am J Health-Syst

Pharm. 2005

11. Orsted, Searles, Trowell, et al. Best Practice Recommendation for the Prevention, Diagnosis,

and Treatment of Diabetic Foot Ulcers: Update 2006 Adv Skin Wound Care 2007

12. WOCN Society, Guideline for Management of Wounds in Patients with Lower-Extremity

Neuropathic Disease

13. Bolton, Kirsner,Vileikyte. Clinical practice. Neuropathic diabetic foot ulcers . N Engl J Med. 2004

14. Sheehan, Casell,, et al Percent change in wound area of diabeticfoot ulcers over a 4-week

period is a robust predictor of complete helng in a 12-week prospective trial. Diabetes Care 2003

15. Cavorsi, Vicari, Wirthin, et al Best-pratice algorithms for the use of bilayered living cell therapy…

Wound Repair Regen. 2006

16. Veves, Flanga, armstrong, et al. Graftskin, a human skin equivilent, is effective in management

of noninfected neuropathic diabetic foot ulcer. Diabetes Care 2001

ResourcesPatient Motivation

1. Patient-Centered Communication: Core Skills for Motivation and

Change Activity Expires: 12-01-2011 http://www.impactedu.net/index.htm

2. Motivational Enhancement Therapy (article) http://trilogy200.respironics.com/pdf/1045805_MtvlEnhcmtTherp_Monograph.pdf

3. Motivational interviewing ( article) http://apps.pharmacy.wisc.edu/psw/MIArticle2.pdf

4. Smoking Cessation Resource link http://www.medicinenet.com/weight_control_and_smoking_cessation/eugene-or_city.htm

5. Diabetic Nutrition Education http://www.peacehealth.org/apps/course/CDetails.asp?CourseID=19

http://www.oregonmedicalgroup.com/index.cfm?fuseaction=site.content&type=aafphand&destination=/online/famdocen/home/common/diabetes/living/349.membersite.membersite.html

6. Wagner and University of Texas Grading Scales for Diabetic Foot Ulcers

http://www.medicalcriteria.com/site/index.php?option=com_content&view=article&id=114%3Adbtfoot&catid=49%3Adiabetes&Itemid=80&lang=en