Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update)

Bus, Sicco A.; Lavery, Lawrence A.; Monteiro‐Soares, Matilde; Rasmussen, Anne; Raspovic, Anita; Sacco, Isabel C.N.; Netten, Jaap J. van

doi:10.1002/dmrr.3269

Cited by 369 publications

(681 citation statements)

References 147 publications

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“…30,31 Other performanceapproach goals that are related to the reduction of foot ulcer risk and can be monitored using (wearable) smart technology are continuous low plantar pressures in the footwear worn, high adherence to the targeted individualized interventions, and a reduced number of abnormal temperature differences between the feet. 19 Personalized treatment should be delivered in an integrated approach, in line with current IWGDF recommendations. 19 For this, specialized interdisciplinary ulcer prevention teams need to be set up.…”

Section: A Paradigm Shift Towards Personalized Medicinementioning

confidence: 93%

“…19 Personalized treatment should be delivered in an integrated approach, in line with current IWGDF recommendations. 19 For this, specialized interdisciplinary ulcer prevention teams need to be set up. These teams should work hand in hand with the current interdisciplinary teams focusing on ulcer healing, with some professionals/ clinicians (eg, podiatrists, shoe technicians, psychologists, and rehabili- 19 Three cornerstones of the IWGDF Prevention Guideline are depicted: education (green), footwear (brown), and risk factor treatment (blue).…”

Section: A Paradigm Shift Towards Personalized Medicinementioning

confidence: 93%

“…Currently, the three patients shown are all considered to be at high risk, as they all have an ulcer in their history. 19 To provide better, and personalized, treatment, epidemiological studies should take more detail into account, such as the number of ulcers, healing time per ulcer, length of ulcer-free periods, time since last ulcer, ulcer locations, and most importantly: the interdependency of all these outcomes. Methodologies to analyze the interdependencies of multiple, recurrent, exacerbated or new ulcers are available, such as the "subsequent injury categorization".…”

Section: A Paradigm Shift Towards Personalized Medicinementioning

confidence: 99%

“…19 For this, specialized interdisciplinary ulcer prevention teams need to be set up. These teams should work hand in hand with the current interdisciplinary teams focusing on ulcer healing, with some professionals/ clinicians (eg, podiatrists, shoe technicians, psychologists, and rehabili- 19 Three cornerstones of the IWGDF Prevention Guideline are depicted: education (green), footwear (brown), and risk factor treatment (blue). In stratified healthcare, a person would be screened for the five irreversible risk factors that determine someone's risk status, 19 and all guideline recommendations on education, footwear and risk factor treatment that are given for their risk stratum apply.…”

Section: A Paradigm Shift Towards Personalized Medicinementioning

confidence: 99%

“…These teams should work hand in hand with the current interdisciplinary teams focusing on ulcer healing, with some professionals/ clinicians (eg, podiatrists, shoe technicians, psychologists, and rehabili- 19 Three cornerstones of the IWGDF Prevention Guideline are depicted: education (green), footwear (brown), and risk factor treatment (blue). In stratified healthcare, a person would be screened for the five irreversible risk factors that determine someone's risk status, 19 and all guideline recommendations on education, footwear and risk factor treatment that are given for their risk stratum apply. In personalized medicine, specific recommendations on education, footwear and risk factor treatment are applicable to individual patients, depending on an individual assessment of multiple modifiable risk factors (eg, biomechanical and behavioral) and personalized treatment plans.…”

Section: A Paradigm Shift Towards Personalized Medicinementioning

confidence: 99%

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The future for diabetic foot ulcer prevention: A paradigm shift from stratified healthcare towards personalized medicine

Netten

Woodburn

Bus

2020

Diabetes Metabolism Res

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Prevention of diabetic foot ulcers is important to reduce the burden of diabetic foot disease. However, we found that ulcer prevention is underexposed in research and clinical practice. Barriers to explain this are seen in patient's goal‐setting; in the lack of interdisciplinary teams for ulcer prevention; in sample sizes and funding for research; in industrial engagement; and in limited understanding of ulcer development. Rather than separately solving these barriers, we propose a paradigm shift from stratified healthcare towards personalized medicine for diabetic foot disease. Personalized medicine aims to deliver the right treatment to the right patient at the right time, based on individual diagnostics. Different treatment strategies should be available for different patients, delivered in an integrated, objective, quantitative and evidence‐based approach. More than on the classical risk factors of peripheral neuropathy and peripheral artery disease, individual diagnostics should focus on modifiable risk factors for ulceration. This includes structured biomechanical and behavioral profiling, while new research with (big) data science may identify additional risk factors, such as geographical or temporal patterns in ulceration. Industry involvement can drive the development of wearable instruments and assessment tools, to facilitate large‐scale individual diagnostics. For a paradigm shift towards personalized medicine in prevention, large‐scale collaborations between stakeholders are needed. As each ulcer episode not prevented costs about €10,000 in medical costs alone, such investments can be cost‐effective. We hope to see more discussions around this paradigm shift, and increasing investments of energy and money in diabetic foot ulcer prevention in research and clinical practice.

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Section: A Paradigm Shift Towards Personalized Medicinementioning

confidence: 93%

Section: A Paradigm Shift Towards Personalized Medicinementioning

confidence: 93%

Section: A Paradigm Shift Towards Personalized Medicinementioning

confidence: 99%

Section: A Paradigm Shift Towards Personalized Medicinementioning

confidence: 99%

Section: A Paradigm Shift Towards Personalized Medicinementioning

confidence: 99%

See 3 more Smart Citations

The future for diabetic foot ulcer prevention: A paradigm shift from stratified healthcare towards personalized medicine

Netten

Woodburn

Bus

2020

Diabetes Metabolism Res

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Diabetic Foot Ulcers

Armstrong

Tan

Boulton

et al. 2023

JAMA

212

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ImportanceApproximately 18.6 million people worldwide are affected by a diabetic foot ulcer each year, including 1.6 million people in the United States. These ulcers precede 80% of lower extremity amputations among people diagnosed with diabetes and are associated with an increased risk of death.ObservationsNeurological, vascular, and biomechanical factors contribute to diabetic foot ulceration. Approximately 50% to 60% of ulcers become infected, and about 20% of moderate to severe infections lead to lower extremity amputations. The 5-year mortality rate for individuals with a diabetic foot ulcer is approximately 30%, exceeding 70% for those with a major amputation. The mortality rate for people with diabetic foot ulcers is 231 deaths per 1000 person-years, compared with 182 deaths per 1000 person-years in people with diabetes without foot ulcers. People who are Black, Hispanic, or Native American and people with low socioeconomic status have higher rates of diabetic foot ulcer and subsequent amputation compared with White people. Classifying ulcers based on the degree of tissue loss, ischemia, and infection can help identify risk of limb-threatening disease. Several interventions reduce risk of ulcers compared with usual care, such as pressure-relieving footwear (13.3% vs 25.4%; relative risk, 0.49; 95% CI, 0.28-0.84), foot skin measurements with off-loading when hot spots (ie, greater than 2 °C difference between the affected foot and the unaffected foot) are found (18.7% vs 30.8%; relative risk, 0.51; 95% CI, 0.31-0.84), and treatment of preulcer signs. Surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection are first-line therapies for diabetic foot ulcers. Randomized clinical trials support treatments to accelerate wound healing and culture-directed oral antibiotics for localized osteomyelitis. Multidisciplinary care, typically consisting of podiatrists, infectious disease specialists, and vascular surgeons, in close collaboration with primary care clinicians, is associated with lower major amputation rates relative to usual care (3.2% vs 4.4%; odds ratio, 0.40; 95% CI, 0.32-0.51). Approximately 30% to 40% of diabetic foot ulcers heal at 12 weeks, and recurrence after healing is estimated to be 42% at 1 year and 65% at 5 years.Conclusions and RelevanceDiabetic foot ulcers affect approximately 18.6 million people worldwide each year and are associated with increased rates of amputation and death. Surgical debridement, reducing pressure from weight bearing, treating lower extremity ischemia and foot infection, and early referral for multidisciplinary care are first-line therapies for diabetic foot ulcers.

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