Australian and International Guidelines on the management of diabetic foot disease

This is the fourth article in the “DFA Guides You Through” series on Australian and International diabetic foot disease guidelines.

In this article, we compare the Australian guideline and IWGDF guidance on the management of diabetic foot disease. Management of diabetic foot disease is divided in three topics: organization of care and ulcer assessment; footwear and offloading; and wound healing interventions.

The importance of a multidisciplinary team to organize diabetic foot care is stressed in both guidelines. Evidence is limited on this topic, but expert opinion is clear. Both guidelines recommend treatment of diabetic foot disease by a multidisciplinary team including diabetologist, (orthopaedic) surgeon, vascular surgeon, endovascular interventionist/radiologist, podiatrist, diabetes nurse, and pedorthist / orthotist. There is no agreed definition for a multidisciplinary team, so no further recommendations to the specific organization of this team is made in either guideline. When access to a multidisciplinary team is limited, or for uncomplicated ulcers, both guidelines describe that a first level of treatment consisting of general practitioner with podiatrist and/or wound care nurse may suffice.

Various systems are available for assessment of foot ulcers, such as the University of Texas, PEDIS, WIfI, and SINBAD. Each system has its advantages and disadvantages, as nicely described in this paper by Dr. Game. The University of Texas is one of the longest standing classification systems, and is recommended in the Australian guideline. No specific system is recommended in the IWGDF guidance, they only list the items that should minimally be assessed (type, cause, site, depth, and infection). The bottom line is the same in both: to understand outcomes of treatment, we need careful assessment and classification of each ulcer.

Offloading is paramount to heal plantar diabetic foot ulcers. Non-removable knee-high offloading devices are considered the gold standard in both guidelines. However, that can be contraindicated for various reasons, such as the need for regular dressing changes or the risk of falls. Both guidelines recommend considering other devices in such cases. IWGDF specifies this further, recommending a trapped approach: non-removable knee-high are the preferred method of offloading, when contra-indicated a removable knee-high device should be provided, and when these are contra-indicated as well an offloading shoe or cast shoe can be chosen. In addition, IWGDF recommends using shoe modifications or felted foam in combination with adequate footwear as last resort, while clearly recommending against the use of conventional or standard therapeutic to heal an ulcer.

A difference between both guidelines is surgical offloading, as these are only included in the IWGDF guidance. When conservative treatment fails, Achilles tendon lengthening, single or pan metatarsal head resection, or joint arthroplasty are suggested to heal a plantar neuropathic ulcer, and digital flexor tenotomy for a toe ulcer. However, high-quality evidence in this area is scarce, and surgery should only be considered in selected patients while taking potential complications into account.

The last part concerns wound healing interventions. These can be separated in basic interventions and advanced adjunctive interventions. Recommendations for basic interventions are primarily based on expert opinion, advocating sharp debridement and the use of topical hydrogel dressings, with exudate control, comfort and costs as principal criteria to guide dressing selection. Both guidelines, however, stress the insufficient evidence for superiority of one dressing over another.

Advanced adjunctive interventions are only recommended as part of a comprehensive wound management program in specialist centres. Both guidelines agree that topical negative pressure therapy and hyperbaric oxygen therapy may be considered for specific ulcers, although the debate surrounding these interventions is reflected in the cautious texts following these recommendations. A difference exists with regard to larval therapy and skin replacement therapies. These receive the same cautious recommendations as topical negative pressure and hyperbaric oxygen in the Australian guideline, but IWGDF recommends against their use. This seems to result from a more strict assessment of the evidence by the IWGDF working group, as well as the inclusion of some more recent publications. Other advanced adjunctive interventions (growth factors, electricity, magnetism, ultrasound, shockwaves, and systemic treatments such as drugs and herbal therapies) are recommended against in the IWGDF guidance, and not recommended due to the limited evidence in the Australian guideline.

The overview of all recommendations in both guidelines can be found in this table.

As described in our overview of both guidelines, peripheral artery disease and infection related recommendations were outside the scope of the work undertaken for the Australian guideline. We will not summarize the IWGDF recommendations in our following article. The recommendations can be found here (peripheral artery disease) and here (infection).

In conclusion, the Australian guideline and IWGDF guidance are similar on the vast majority of topics. Diabetic foot disease needs to be managed by a multidisciplinary team, standardized ulcer assessment is a key first step of treatment, non-removable devices are the gold standard for offloading but when contra-indicated other options are available, and advanced adjunctive wound healing interventions should only be provided by specialized centres when accepted standards of good quality care do not heal an ulcer.

The next article in this “DFA Guides You Through” series will discuss IWGDF recommendations on peripheral artery disease and infection. 

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