Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update)

Abstract

The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis, prognosis, and management of peripheral artery disease (PAD) in patients with foot ulcers and diabetes and updates the previous IWGDF Guideline. Up to 50% of patients with diabetes and foot ulceration have concurrent PAD, which confers a significantly elevated risk of adverse limb events and cardiovascular disease. We know that the diagnosis, prognosis, and treatment of these patients are markedly different to patients with diabetes who do not have PAD and yet there are few good quality studies addressing this important subset of patients. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to devise clinical questions and critically important outcomes in the patient‐intervention‐comparison‐outcome (PICO) format, to conduct a systematic review of the medical‐scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We here present the updated 2019 guidelines on diagnosis, prognosis, and management of PAD in patients with a foot ulcer and diabetes, and we suggest some key future topics of particular research interest.

Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update)

“…Assess the severity of infection using the IWGDF/ISDA classification criteria, 4,6 and in patients with PAD, we recommend using the WIfI (wound/ischaemia/infection) system to stratify amputation risk and revascularisation benefit. 3,6 For communication among health care professionals, we recommend the SINBAD system, which can also be used for audit of outcome of populations. 6 7 | ULCER TREATMENT Foot ulcers will heal in the majority of patients if the clinician bases treatment on the principles outlined below.…”

“…However, clinicians might consider revascularisation at higher pressure levels in patients with extensive tissue loss or infection, as discussed in more detail in the IWGDF PAD Guideline. 3 • When an ulcer fails to show signs of healing within 6 weeks, despite optimal management, consider revascularisation, irrespective of the results of the vascular diagnostic tests described above.…”

“…The Practical Guidelines are based on the IWGDF Guidelines 2019, consisting of evidence-based guideline chapters on • Classification of diabetic foot ulcers 6 The authors, as members of the editorial board of the IWGDF, have summarized the information from these six chapters and also provide additional advice based on expert opinion in selected areas for which the guideline chapters were not able to provide evidencebased recommendations. We refer the reader for details and background to the six evidence-based guideline chapters [1][2][3][4][5][6] and our development and methodology document 7 ; should this summary text appear to differ from information of these chapters, we suggest the reader defer to the specific guideline chapters. [1][2][3][4][5][6] Because terminology in this multidisciplinary area can sometimes be unclear, we have developed a separate IWGDF Definitions and Criteria document.…”

“…We refer the reader for details and background to the six evidence-based guideline chapters [1][2][3][4][5][6] and our development and methodology document 7 ; should this summary text appear to differ from information of these chapters, we suggest the reader defer to the specific guideline chapters. [1][2][3][4][5][6] Because terminology in this multidisciplinary area can sometimes be unclear, we have developed a separate IWGDF Definitions and Criteria document. 8 The information in these practical guidelines is aimed at the global community of health care professionals involved in the care of persons with diabetes.…”

Treatment of lower limb ischaemia in patients with diabetes

“…The most useful tests to predict wound healing (>25% higher chance) are skin perfusion pressure ≥40 mm Hg, toe pressure ≥30 mm Hg and transcutaneous pressure of oxygen (TcPO2) ≥ 25 mm Hg. 7,20 It is prudent to aim for a toe pressure of at least >60 mm Hg post-revascularization. The most recent 2019 International Working Group on the Diabetic Foot (IWGDF) guidelines recommended aiming to improve perfusion to the foot as much as possible.…”