The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes and a foot ulcer

AimsOffloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes‐related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence‐based guideline on offloading interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline.Materials and MethodsWe followed the GRADE approach by devising clinical questions and important outcomes in the PICO (Patient‐Intervention‐Control‐Outcome) format, undertaking a systematic review and meta‐analyses, developing summary of judgement tables and writing recommendations and rationales for each question. Each recommendation is based on the evidence found in the systematic review, expert opinion where evidence was not available, and a careful weighing of GRADE summary of judgement items including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability.ResultsFor healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, use a non‐removable knee‐high offloading device as the first‐choice offloading intervention. If contraindications or patient intolerance to non‐removable offloading exist, consider using a removable knee‐high or ankle‐high offloading device as the second‐choice offloading intervention. If no offloading devices are available, consider using appropriately fitting footwear combined with felted foam as the third‐choice offloading intervention. If such a non‐surgical offloading treatment fails to heal a plantar forefoot ulcer, consider an Achilles tendon lengthening, metatarsal head resection, joint arthroplasty, or metatarsal osteotomy. For healing a neuropathic plantar or apex lesser digit ulcer secondary to flexibile toe deformity, use digital flexor tendon tenotomy. For healing rearfoot, non‐plantar or ulcers complicated with infection or ischaemia, further recommendations have been outlined. All recommendations have been summarised in an offloading clinical pathway to help facilitate the implementation of this guideline into clinical practice.ConclusionThese offloading guideline recommendations should help healthcare professionals provide the best care and outcomes for persons with diabetes‐related foot ulcers and reduce the person's risk of infection, hospitalisation and amputation.

Section: A)mentioning

confidence: 99%

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update)

Bus

Armstrong

Crews

et al. 2023

“…Consider the use of hyperbaric oxygen as an adjunct therapy in neuro-ischaemic or ischaemic diabetes-related foot ulcers where standard of care alone has failed and where resources already exist to support this intervention (Conditional; Low). 13. Consider the use of topical oxygen as an adjunct therapy to standard of care for wound healing in people with diabetesrelated foot ulcers where standard of care alone has failed and resources exist to support this intervention (Conditional; Low).…”

Section: List Of Recommendationsmentioning

confidence: 99%

“…We did not include offloading interventions or systemic interventions designed to treat infection or interventions that were designed to improve limb perfusion unless they were pharmacological in nature and reported wound healing, as these interventions were included in other working group guidelines. [12][13][14] Third, we systematically reviewed the literature and appraised all studies addressing the above agreed upon clinical questions. Unlike previous versions of the guidelines, in view of the huge increase in the volume of literature and the need to assess only the evidence of the highest quality in formulating guidelines, we included only randomised controlled trials (RCTs) in our systematic review.…”

Section: Interventions (Topical and Systemic Therapeutic Agents) Incl...mentioning

confidence: 99%

Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update)

Chen,

Vilorio,

Dhatariya

et al. 2023

AimsPrinciples of wound management, including debridement, wound bed preparation, and newer technologies involving alternation of wound physiology to facilitate healing, are of utmost importance when attempting to heal a chronic diabetes‐related foot ulcer. However, the rising incidence and costs of diabetes‐related foot ulcer management necessitate that interventions to enhance wound healing of chronic diabetes‐related foot ulcers are supported by high‐quality evidence of efficacy and cost effectiveness when used in conjunction with established aspects of gold‐standard multidisciplinary care. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence‐based guideline on wound healing interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline.Materials and MethodsWe followed the GRADE approach by devising clinical questions and important outcomes in the Patient‐Intervention‐Control‐Outcome (PICO) format, undertaking a systematic review, developing summary of judgements tables, and writing recommendations and rationale for each question. Each recommendation is based on the evidence found in the systematic review and, using the GRADE summary of judgement items, including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability, we formulated recommendations that were agreed by the authors and reviewed by independent experts and stakeholders.ResultsFrom the results of the systematic review and evidence‐to‐decision making process, we were able to make 29 separate recommendations. We made a number of conditional supportive recommendations for the use of interventions to improve healing of foot ulcers in people with diabetes. These include the use of sucrose octasulfate dressings, the use of negative pressure wound therapies for post‐operative wounds, the use of placental‐derived products, the use of the autologous leucocyte/platelet/fibrin patch, the use of topical oxygen therapy, and the use of hyperbaric oxygen. Although in all cases it was stressed that these should be used where best standard of care was not able to heal the wound alone and where resources were available for the interventions.ConclusionsThese wound healing recommendations should support improved outcomes for people with diabetes and ulcers of the foot, and we hope that widescale implementation will follow. However, although the certainty of much of the evidence on which to base the recommendations is improving, it remains poor overall. We encourage not more, but better quality trials including those with a health economic analysis, into this area.

“…Current guidelines on PAD associated with diabetes-related foot highlight that the combination of infection plus PAD portents a poor clinical outcome if both are not treated adequately. 7 Therefore, in case of infection, the patient should be assessed for the presence and severity of PAD. As clinical assessment is often unreliable, it is important to also perform non-invasive tests, for example, Doppler waveform analysis combined with ankle pressure measurement, as well as toe pressure measurements.…”

Section: Rationalementioning

confidence: 99%

“…Although rarely the primary cause of foot ulcers, the presence of PAD increases the risk of an ulcer becoming infected 4,[15][16][17] and adversely affects the outcome of infection .4,18,19 Because the combination of infection with PAD is associated with a markedly increased risk of poor healing and amputation, clinicians should evaluate the state of wound perfusion and the potential need for a revascularisation procedure as soon as possible in all patients with a DFI. 7 Factors that predispose to foot infection include having a wound that is deep, long-standing, recurrent, or of traumatic aetiology; the presence of diabetes-related immunological perturbations, particularly neutrophil dysfunction; and having concomitant chronic renal failure. 16,[18][19][20][21][22][23] Although examined in only a few studies, a history of chronic hyperglycaemia may predispose to DFIs, and the presence of hyperglycaemia at presentation may suggest a rapidly progressive or destructive (necrotising) infection.…”

Section: Introductionmentioning

confidence: 99%

IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes‐related foot infections (IWGDF/IDSA 2023)

Senneville,

Albalawi,

van Asten

et al. 2023

The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the management and prevention of diabetes‐related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus.The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient‐important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes‐related foot care to inform clinical care around patient‐important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations.The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes‐related foot problems.We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes‐related foot disease.