Exploring Non-Amputation Treatments for Diabetic Foot Ulcers

Diabetic foot

Hello, Doctor.
My mother is 87 years old and has diabetes.
She previously had a heel injury that improved with hyperbaric oxygen therapy.
In February of this year, her heel cracked again, and she has also developed wounds on her toes.
We have conducted cardiovascular examinations, and the doctor mentioned that amputation may be necessary.
We are very hopeful to make further efforts to avoid amputation, as we have seen some cases online where patients healed without it.
Could you please advise us on what steps we can take? We are currently considering trying hyperbaric oxygen therapy again.
Additionally, we found information online about "Becaplermin" (recombinant human platelet-derived growth factor) which is said to help treat diabetic wounds, but we are unsure where to obtain this medication.
We are eager to explore any treatment options other than amputation, and we appreciate your guidance.
Thank you!

tulip, 50~59 year old female. Ask Date: 2008/03/23

Dr. Shi Guangzhong reply Internal Medicine

The causes of amputation are often not due to a single factor, but rather the combined effects of multiple factors, including neuropathy, ischemic disease, ulcers, poor wound healing, and infections.
Your mother has already undergone cardiovascular examinations; I am unsure of the results.
If peripheral vascular disease has caused inadequate blood flow to the lower limbs, it can lead to tissue hypoxia and nutrient deficiency, as well as reduced elimination of metabolic waste, which significantly affects wound healing.
As for the efficacy of hyperbaric oxygen therapy, it would be advisable for your physician to reassess this.
Given your mother's advanced age, existing foot injuries, and recurrent infections, wound healing may be quite slow.
If gangrene has set in, it indicates that blood flow to the necrotic tissue has been completely obstructed, typically requiring surgical intervention.
Regardless of the outcome, it is crucial that your mother maintains stable blood sugar levels, as stable glucose control can reduce the risk of recurrent infections in wounds.

The Department of Health has recently approved a new genetically engineered topical preparation, Becaplermin (recombinant human platelet-derived growth factor), for market release.
This product is a recombinant platelet-derived growth factor gel indicated for promoting the healing of full-thickness diabetic ulcers measuring less than or equal to 5 cm².
It is produced by inserting the gene for human platelet-derived growth factor B chain into yeast, resulting in a polypeptide that has the same activity as naturally occurring human platelet-derived growth factor.
It enhances the formation of granulation tissue and promotes wound healing while shortening healing time through its effects on cell chemotaxis and proliferation related to wound repair.
Contraindications for Becaplermin include known allergies to any component of the product and the presence of neoplasms at the application site.
Precautions: Although the likelihood of systemic absorption is low, caution is advised for patients with malignant tumors.
Side effects: The incidence of ulcer-related side effects (particularly infections, cellulitis, or osteomyelitis) is similar to that observed with placebo gel.
Since there are no specific therapeutic agents for diabetic ulcers, this product is a topical gel, and due to clinical data indicating low systemic absorption, the Department of Health has approved it for market release without requiring domestic clinical trials, to be used as a treatment for diabetic patients with ulcers measuring less than or equal to 5 cm².
This product is available only by prescription, and after its release, it will be monitored.
During the monitoring period (seven years from the date of approval), the manufacturer must collect domestic and international reports of adverse effects and submit them biannually to the Department of Health's Adverse Drug Reaction Reporting Center to ensure medication safety for the public.
Currently, the only available recombinant PDGF product for the treatment of chronic diabetic wounds is Regranex Gel (Becaplermin 0.01%), which is quite expensive.

Reply Date: 2008/03/23

More Info

Diabetic foot ulcers are a significant concern for individuals with diabetes, particularly in older patients like your mother. The risk of amputation often arises from a combination of factors, including poor circulation, neuropathy, and infection. However, there are several non-amputation treatment options available that can help manage and potentially heal diabetic foot ulcers.

1. Wound Care Management
Proper wound care is crucial for healing diabetic foot ulcers. This includes:
- Debridement: This is the process of removing dead or infected tissue from the wound. It can be done surgically or through enzymatic methods. Regular debridement can promote healing and reduce the risk of infection.

- Moisture Management: Keeping the wound moist can facilitate healing. Hydrocolloid dressings or alginate dressings can be beneficial in maintaining an optimal moisture balance.

- Infection Control: If there are signs of infection, such as increased redness, swelling, or discharge, it’s essential to consult a healthcare provider for appropriate antibiotic treatment.

2. Pressure Relief
Reducing pressure on the ulcer is vital. This can be achieved through:
- Specialized Footwear: Custom-made shoes or offloading devices can help distribute weight away from the ulcerated area. These shoes are designed to provide cushioning and support while preventing further injury.

- Total Contact Casting: This technique involves applying a cast that conforms to the shape of the foot, distributing pressure evenly and allowing the ulcer to heal.

3. Advanced Therapies
Several advanced therapies can be considered:
- Hyperbaric Oxygen Therapy (HBOT): As you mentioned, your mother has previously undergone HBOT. This therapy involves breathing pure oxygen in a pressurized room, which can enhance oxygen delivery to tissues and promote healing. It’s essential to discuss with her healthcare provider whether a repeat session is appropriate.

- Becaplermin (Regranex): This recombinant human platelet-derived growth factor gel has been shown to promote healing in diabetic ulcers. It works by stimulating cell growth and tissue repair. It is available by prescription, so you will need to consult her physician to obtain it. The doctor can provide guidance on its use and monitor for any potential side effects.

4. Nutritional Support
Nutrition plays a vital role in wound healing. Ensuring that your mother has a balanced diet rich in vitamins and minerals, particularly protein, vitamin C, and zinc, can support the healing process. Consulting a dietitian may be beneficial.

5. Blood Sugar Control
Maintaining stable blood glucose levels is crucial in managing diabetic foot ulcers. High blood sugar can impede healing and increase the risk of infection. Regular monitoring and adjustments to her diabetes management plan may be necessary.

6. Regular Monitoring and Follow-Up
Frequent check-ups with her healthcare provider are essential to monitor the progress of the ulcer and make necessary adjustments to her treatment plan. Early intervention can prevent complications and the need for more invasive procedures.

Conclusion
While the prospect of amputation can be daunting, there are various non-amputation treatments available for diabetic foot ulcers. It is crucial to work closely with her healthcare team to explore these options and develop a comprehensive care plan tailored to her needs. Each case is unique, and what works for one patient may not work for another, so ongoing communication with her medical team is vital. Your proactive approach in seeking alternatives is commendable, and with the right care, there is hope for healing without the need for amputation.

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