The Society for Vascular Surgery (SVS), the American Podiatric Medical Association (APMA) and the Society for Vascular Medicine (SVM) collaboratively have published their first-ever set of clinical practice guidelines for treating the diabetic foot, based on a meta-analysis of the available literature.
The guidelines, “The Management of the Diabetic Foot,” were developed after three years of study and were published online in late January and in print in the February 2016 edition of Journal for Vascular Surgery.
Anil P Hingorani is the lead author for the SVS writing group, which researched and wrote the guidelines; that group operates under the SVS Document Oversight Committee.
With diabetes a major worldwide problem and little data on treatments, the need for detailed, diabetic foot clinical guidelines from multiple disciplines was great, says Hingorani.
“There has been very little level one randomised data looking at treatment,” Hingorani says. “This is such a major problem in the US and worldwide, but there has been so little written information and no guidelines combining the various viewpoints of these specialties.”
Writing group members used the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system to rate the quality of evidence and the strength of recommendations. The Mayo Clinic provided meta-analysis assistance.
The committee synthesised the points of view of the three different medical professions by researching one another’s treatment protocols.
Vascular surgeons and vascular medicine specialists read literature from podiatry and vice versa, for example, and all participants concentrated on infectious disease control and guidelines, a large component of the finished document.
Collaboration was key, Hingorani reports. “We had multiple disciplines looking at the problem to bring the best information from each field to develop the guidelines,” he says, though only limited “high-quality evidence” was available for many of the critical questions.
One of the findings that physicians may find surprising was the importance of the total contact cast in the treatment of plantar diabetic foot ulcers, which the committee found was is supported by robust data. Off-loading takes all direct pressure off the ulcer through use of a cast, a non-removable, fixed ankle walking boot or similar treatment.
“Total contact casting (TCC) is so under-utilised,” Hingorani says. “I think some surgeons may find it surprising and it may raise a few eyebrows. Many surgeons are not aware of how strong the evidence is for TCC. It is not new but not widely understood or implemented.”
Other important findings and points include:
- Guidelines help identify which patients are at high risk.
- The guidelines comprise a living document which will be updated with new evidence periodically.
- The guidelines include a review of the various types of wound care for the diabetic foot, summarising and grading the best available evidence and setting some protocols to help treat foot ulcers.
- Guidelines will need to be implemented into training programs.
“Management of Diabetic Foot” clinical practice guidelines will be available soon to physicians through the free app, SVS iPG, available through Google Play and the App Store.
“This is an important contribution by the SVS,” Hingorani says, “since the new guidelines can improve patient care, save lives and limbs and reduce costs.”