Literature Review
Introduction
Patients with diabetes mellitus easily develop ulceration on their lower limbs due to reduced sensitivity associated with diabetic neuropathy. Diabetes complication contributes to slow wound healing processes and increased risks of developing a complication that could lead to limb amputation. The main issue affecting diabetic patients with foot ulceration is the risk of amputation. This topic is important among diabetic patients as it provides them with necessary knowledge on the management of their condition through blood glucose control, proper care of foot ulcers, and other consideration for managing foot ulcers.
A diabetic foot ulcer is a diabetic complication affecting about 15% of all patients with diabetes mellitus. Ensuring that patients get a continuous assessment, early diagnosis, and proper management of foot ulceration can reduce the risk or morbidity and mortality associated with amputation. Some of the contributing factors for diabetic foot include the presence of peripheral arterial disease, diabetes neuropathy, anatomical deformities of the foot, poor blood glucose control, and a history of foot ulcers. Other contributing factors include immunosuppression associated with infectious diseases, diabetes, or other underlying illnesses. Immunosuppression related to diabetes also manifests through increased apoptosis of T lymphocytes that inhibits wound healing (Aumiller & Anderson, 2015). The risk of foot ulceration in patients with diabetes may be as high as 68 in every 1000 patients (Jarnert, Kalani, Ryden, & Bohm, 2012; Kostev, Dippel, Rockel, & Sieqmund, 2012). Approximately 20% of diabetic patients admitted in hospitals have foot ulcerations. Diabetic foot ulceration has also been associated with emotional and physical stress and reduction in productivity (Yazdanpanah, Nasiri, & Adarvishi, 2015; Alexiadou & Doupis, 2012). Rehabilitation and wound care services after amputation increase the economic burden of families.
Other studies have estimated this risk to be up to 30 times higher among diabetic patients (Fernando, et al., 2016). The proper control of glycemic levels has been associated with reduced risk of amputation among patients with foot ulcerations and accelerated healing. The purpose of this essay is to provide a literature review on the importance of appropriate glycemic control among diabetes patients with foot ulcerations. The PICOT question that will be used in this literature review will be, “In diabetic patients with foot ulcerations (P), can the implementation of an intensive glycemic control therapy (I) as compared to the use of standard glycemic control (C) promote accelerated healing of the wound (O) over time (T)?”
Methods
During the literature search for this PICOT question, the research papers included in this project were obtained from databases that contained health research studies. These databases included Cochrane Library, MEDLINE, PubMed, and the BioMed Clinical Evidence. These websites contain numerous studies that have been peer-reviewed and published in recognized journals. The databases contained different levels of evidence. Level I and level II evidence were selected for this project. Level I evidence consists of large and well-conducted randomized controlled trials or peer-reviewed meta-analyses while level II evidence consists of small-randomized controlled trials.
Some of the keywords used while searching for evidence included, type 2 diabetes mellitus, diabetes, glycemic control, glucose-lowering drugs, foot ulceration, diabetic foot, insulin, and diabetic amputated foot. The keywords were based on the use of MeSH terms and the combination of phrases to improve the results obtained. Phrases used included glycemic control and diabetic foot ulceration, improvement of glycemic control and prevention of foot amputation, and long-term versus short-term glucose drugs.
The inclusion criteria were based on research papers that were conducted not more than 5-7 years ago, articles that focused on diabetic participants who had foot ulcerations or amputated limbs, and articles that focused on treatment approaches used in diabetic treatment to prevent diabetic complications or accelerate wound healing. Studies focusing on other groups of patients were not included in the paper. The exclusion criteria also included studies that were conducted before 2011, cohort studies, random articles on the internet that were not peer-reviewed, and research studies considered as level III, IV, or V.
Results
A study conducted on the role of strict glycemic control in improving microcirculation among patients with type 2 diabetes mellitus showed that proper control of blood glucose levels contributed to promotion of microcirculation, which was determined by laser Doppler fluxmetry (32.2 +/- 13.6 vs. 35.3 +/- 13.1, P<0.001). Improvement in the study was more consistent among patients using oral agents than those using insulin. The results also showed that endothelial functions, which were expressed flow-mediated vasodilation decreased among the patients using insulin but remained constant among the patients using the oral agents (Jarnert, Kalani, Ryden, & Bohm, 2012). In a research conducted by Robert Dekker and his colleagues on the effects of a cumulative glycemic burden on diabetic foot incidences, out of 22, 913 patients who had diabetic foot ulcers, the occurrence of peripheral vascular diseases, hypertension, and diabetic neuropathy were associated with higher risk of foot ulcerations. Cumulative glycemic burden and poor management of these conditions were associated with an increased risk of foot ulcers. The mean cumulative burden of glycemic control among patients with foot ulcers was higher than in patients without ulcerations (2781.5 versus 1302.8 P<0.001) (Dekker, Qin, Ho, & Kadakia, 2016). Proper control of blood glucose levels without managing other underlying diseases may not promote wound healing.
In a research conducted by Malindu Fernando and her colleagues, based on the randomized controlled trials and evidence obtained from other sources, they found out that using intensive glycemic control reduced the risk of limb amputation in type 2 diabetic patients (Fernando, et al., 2016). Results obtained from another research that investigated the use of herbal approaches to reduce inflammation among diabetic patients with chronic foot ulceration showed an 85% improvement and limb rescue after using the treatment. Tumor necrosis factor alpha, skin temperature and circulation in the lower limbs were observed in participants in this study. The results showed a gradual healing of the ulcerations (P=0.037). Herbal treatment options considered in this research included aloe vera, fenugreek, and ginger. These herbs were not used in specific measures among the patients (Leung, Pang, Wong, & Cheng, 2012). Application of other wound care practices supported the evidence obtained from these studies.
In a study on the risk of diabetic foot ulceration among 23, 395 patients being treated with insulin glargine and 9,638 patients on neutral protamine Hagedorn (NPH) insulin, the results obtained showed that patients on insulin glargine had a 64% lower chance of getting foot ulcerations than those on NPH insulin (Kostev, Dippel, Rockel, & Sieqmund, 2012). The use of long-acting insulin glargine was similar to using intensive glycemic control approaches seen in other studies.
Discussion
In the study aimed at determining changes in skin microcirculation among diabetic patients, the researchers concluded that glycemic control improved skin microcirculation but did not have a significant effect on endothelial function among type 2 diabetes patients (Jarnert, Kalani, Ryden, & Bohm, 2012). The research conducted by Fernando and her colleagues indicated that the role of intensive glycemic control in managing foot ulcers was multidisciplinary and relied on application of other interventions such as proper wound cleaning and care and participants’ dietary patterns (Fernando, et al., 2016). The changes in skin microcirculation and evidence showing an improvement in foot ulceration management among patients using better glycemic control methods can be used as evidence to implement these strategies in clinical settings.
In the study that aimed to investigate the difference between the long-acting basal insulin glargine and the NPH insulin, the researchers concluded that insulin glargine significantly reduced the risk of diabetic foot ulceration among diabetes patients. The researchers suggested the importance of conducting prospective long-term randomized controlled trials to confirm the results obtained in their research (Kostev, Dippel, Rockel, & Sieqmund, 2012). The herbal treatment option used in one of the studies had similar characteristics as other conventional glucose-lowering therapies (Leung, Pang, Wong, & Cheng, 2012). Although cumulative glycemic burden was not related to Charcot arthropathy, it was considered a contributing factor to diabetic foot ulcers (Dekker, Qin, Ho, & Kadakia, 2016). Poor glycemic control was associated with foot ulcers and amputations among diabetes patients.
Some of the strengths of the studies included their provision of conclusive evidence on the difference between using long-term insulin treatment versus the use of short-term approaches. Most of these studies were also conducted for a longer duration that promoted analysis of the factors affecting the participants and the effectiveness of the tested therapies. Another strength was the exclusion of non-randomized and quasi-randomized trials in the meta-analyses studies that were selected from the database. Most of the participants used had either diabetic foot ulcerations or limb amputations.
Conclusion
Based on the evidence obtained from the studies analyzed in this literature review, proper management of glycemic control among patients with type 2 diabetes mellitus is significant in promoting wound healing and reducing the risks of amputations. Accelerated healing relies on multifaceted factors that include dietary modifications, wound care, and use of glucose-lowering drugs. The literature review shows an association between the use of an intensive glycemic control therapy and effective management of diabetic foot ulceration as compared to the use of standard or short-term treatment options. Prevention of foot ulceration is important in managing patients with diabetes due to the risk of amputation and the financial burden that might be associated with treatment procedures. More research on diabetic foot management through approaches such as herbal treatment should be conducted. Longer prospective studies should be conducted on the effectiveness of using intensive glycemic control in foot ulcers and diabetic foot amputation treatment.
References
Alexiadou, K., & Doupis, J. (2012). Management of Diabetic Foot Ulcers. Diabetes Therapy, 3(1), 4. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3508111/.
Aumiller, W. D., & Anderson, H. (2015). Pathogenesis and Management of Diabetic Foot Ulcers. Journal of the American Academy of PAs, 28(5), 28-34. Retrieved from https://journals.lww.com/jaapa/fulltext/2015/05000/Pathogenesis_and_management_of_diabetic_foot.6.aspx.
Dekker, R. G., Qin, C., Ho, B. S., & Kadakia, A. R. (2016). The Effect of Cumulative Glycemic Burden on the Incidence of Diabetic Foot Disease. Journal of Orthopaedic Surgery and Research, 11: 143. Retrieved from https://josr-online.biomedcentral.com/articles/10.1186/s13018-016-0474-y.
Fernando, M. E., Seneviratne, R. M., Tan, Y. M., Lazzarini, P. A., Sangla, K. S., Cunningham, M., . . . Golledge, J. (2016). Intensive Versus Conventional Glycemic Control for Treating Diabetic Foot Ulcers. The Cochrane Library, Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010764.pub2/full.
Jarnert, C., Kalani, M., Ryden, L., & Bohm, F. (2012). Strict Glycemic Control Improves Skin Microcirculation in Patients with Diabetes: A Report from the Diabetes Mellitus and Diastolic DYsfunction (DADD) Study. Diabetic Vascular Disease Research, 9(4), 287-295. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22377484.
Kostev, K., Dippel, F. W., Rockel, T., & Sieqmund, T. (2012). Risk of Diabetic Foot Ulceration During Treatment with Insulin Glargine and NPH Insulin. Journal of Wound Care, 10, 483-484, 486-489. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23103482.
Leung, P. C., Pang, S. Y., Wong, E. L., & Cheng, K. F. (2012). Inflammatory State of Type II Diabetic Patients with Chronic Ulcers in Response to Herbal Treatment. Foot (Edinburgh, Scotland), 3. 181-185. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22463944.
Yazdanpanah, L., Nasiri, M., & Adarvishi, S. (2015). Literature Review on the Management of Diabetic Foot Ulcer. World Journal of Diabetes, 6(1), 37-53. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4317316/.