Background: Context
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Take a careful history (general history, diabetic control and complications) | Level of Evidence Not Assessed |
| 2 | Take a careful history to establish factors affecting skin breakdown or ulcer healing. | Level of Evidence Not Assessed |
Background
This summary provides background information to assist in reviewing topics within the category of diabetic foot ulcers.Diabetes, a complex metabolic disorder affecting approximately 1.5 million Canadians, is increasing in prevalence, and the age of onset appears to be decreasing, with cases found in children in grade school. Among the aboriginal population, the prevalence of diabetes is at least three times that of the population as a whole. With longevity of the population increasing, the prevalence of complications will continue to increase.
Abnormalities in glycemic control that characterize diabetes mellitus can, over time, cause neuropathy and substantial microvascular and macrovascular changes. Structural changes, neuropathy, vascular insufficiency, pressure and infection all contribute to skin breakdown, ulceration, gangrene and amputation. Diabetic foot ulceration, a significant late-stage complication of diabetes, affects approximately 15% of diabetics and precedes 85% of diabetes-associated non-traumatic foot or leg amputations. The risk of amputation increases 10-fold among patients with both diabetes and end-stage renal disease.
Diabetic foot ulcers are a major cause of morbidity and hospitalization among people with diabetes. Although it is not possible to prevent all diabetic foot problems, the incidence and morbidity can be dramatically reduced through evidence-based prevention and management protocols. A systematic team approach implemented by a specialized interprofessional team can consistently improve limb salvage rates. This team needs to work closely with patients and their families to address lifestyle and self-care issues as well as to treat the ulcer. A careful history can identify issues associated with general health, diabetic control and complications, and factors that may cause ulceration or affect ulcer healing.
References
| Essential Publications |
|---|
| 1 | Diabetes control |
Quality Indicator
|
Type: Prospective Correlation study |
| Stratton IM, Cull CA, Adler AI, Matthews DR, Neil HAW, Holman RR. Additive effects of glycemia and and blood pressure exposure on risk of complications in type 2 diabetes: a prospective observational study (UKPDS 75). Diabetologia (2006);49:1761-1769. | |||
| This is a large prospective study involving 4320 patients with newly diagnosed type 2 diabetes who were investigated to determine if the associations between the risk of developing diabetes-related complications and various combinations of glycemia (HbA1c) and systolic blood pressure (SBP) levels over time is additive. The finding that there was an interaction between the effects of both risk factors on development of complications was corroborated in 887 subjects who participated in a randomized trial that offered various combinations of levels of control of glucose and blood pressure. This study indicates that hyperglycemia and hypertension are related independently and additively with the risk of complications of Type 2 diabetes and their effects. Clinicians must provide rigorous treatment of both risk factors to limit the occurrence of complications. | |||
| 2 | Diabetes control |
Quality Indicator
|
Type: Correlation study |
| Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000;321(7258):405-12. | |||
| This is a large prospective study involving 4585 patients with newly diagnosed type 2 diabetes to determine the association between exposure to glycemia over time with the risk of macrovascular and microvascular complications. Endpoints included death related to diabetes and all-cause mortality, myocardial infarction, stroke, amputation, and microvascular disease. Each 1% reduction in HbA1c was associated with risk reduction for any endpoint of 21% (95% confidence interval 17% to 24%, P<0.0001). This study illustrates the importance of maintaining glycemic control to reduce the risk of complications in patients with Type 2 diabetes. | |||