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New Guidelines Recommend Off-Loading to Increase Likelihood of Diabetic Foot Ulcer Healing

According to consensus guidelines, relieving pressure on the foot through the use of off-loading improves healing outcomes and reduces complications in patients with diabetic foot ulcers…

“The Management of Diabetic Foot Ulcers Through Optimal Off-Loading – Building Consensus Guidelines and Practical Recommendations to Improve Outcomes,” was authored by a multidisciplinary panel of nine experts who were supported by Derma Sciences Inc. The document was developed to provide evidence-based consensus on the optimal use of off-loading as treatment for diabetic foot ulcers (DFUs), a debilitating and costly condition that can lead to amputation of the foot and other lower extremities.

Among patients with diabetes, 15% are at risk for developing a DFU and 85% of lower extremity amputations in diabetic patients are preceded by a foot ulcer. The projected lifetime health care cost for patients with DFUs who undergo amputation is approximately $509,000.

“Publishing this paper is intended to bridge the gap between evidence supporting the effectiveness of off-loading for diabetic foot ulcers and its use in clinical practice, and to guide the wound care decision-making process,” Robert J. Snyder, DPM, MSc, professor and director of Clinical Research at Barry University School of Podiatric Medicine and lead author of the consensus guidelines, stated in a press release. “It is our hope that this manuscript will foster meaningful off-loading of DFUs by the specialist and generalist alike.”

A literature review of approximately 90 studies conducted by the expert panel resulted in the following eight evidence-based consensus guidelines and core recommendations:

  • The VIPs (vascular management, infection management and prevention, and pressure relief) are essential to DFU healing.
  • Adequate off-loading increases the likelihood of DFU healing.
  • For guidance on off-loading the Charcot foot, the panel endorses the Charcot foot in diabetes consensus report published in 2011.
  • Total contact cast (TCC) is the preferred method for off-loading plantar DFUs, as it has most consistently demonstrated the best healing outcomes and is a cost-effective treatment.
  • There currently exists a “gap” between the evidence supporting the efficacy of DFU off-loading and what is performed in clinical practice.
  • The likelihood of DFU healing is increased with off-loading adherence.
  • Advanced therapeutics are unlikely to succeed in improving wound-healing outcomes unless effective off-loading is obtained.
  • The panel supports the development of a per-visit off-loading quality measure to address the gap between evidence of off-loading and its current use in clinical practice.

The likelihood of DFU healing is increased with off-loading adherence, and, current evidence favors the use of non-removable casts or fixed ankle walking braces as optimum off-loading modalities. There currently exists a gap between what the evidence supports regarding the efficacy of DFU off-loading and what is performed in clinical practice despite expert consensus on the standard of care.

Practice Pearls:

  • Among patients with diabetes, 15% are at risk for developing a diabetic foot ulcer.
  • 85% of lower extremity amputations in diabetic patients are preceded by a foot ulcer.
  • Advanced therapeutics are unlikely to succeed in improving wound-healing outcomes unless effective off-loading is obtained.

Journal of the American Podiatric Medical Association, Nov 2014. http://www.japmaonline.org/doi/abs/10.7547/8750-7315-104.6.555