What are the management strategies for patients with diabetes at risk of amputations and high mortality?

Management Strategies for Diabetic Patients at Risk of Amputations and High Mortality

Early identification and comprehensive management of risk factors are essential to prevent amputations and reduce mortality in patients with diabetes, as foot ulcers and amputations represent major causes of morbidity and mortality in this population. 1, 2

Risk Identification

Patients with diabetes who have the following risk factors require close monitoring and aggressive intervention:

• Poor glycemic control 1
• Peripheral neuropathy with loss of protective sensation (LOPS) 1
• Peripheral arterial disease (PAD) 1
• Foot deformities 1
• History of previous foot ulcer or amputation 1
• Preulcerative callus or corn 1
• Visual impairment 1
• Chronic kidney disease (especially patients on dialysis) 1
• Cigarette smoking 1
• Diabetes duration >10 years 1

Comprehensive Foot Examination

• All adults with diabetes should undergo a comprehensive foot examination at least annually, with more frequent assessments for high-risk patients 1
• The examination should include:
  • Visual inspection of skin integrity 1
  • Assessment of foot deformities 1
  • Neurological assessment using 10-g monofilament testing with at least one other assessment (pinprick, temperature, vibration using 128-Hz tuning fork, or ankle reflexes) 1
  • Vascular assessment including inspection and palpation of pedal pulses 1

Preventive Measures

• Patient education on proper foot care, including daily foot inspection, proper nail and skin care, and appropriate footwear 1
• Pressure-relieving footwear for patients with foot deformities or previous ulcers 1
• Regular callus debridement by a foot care specialist 1
• Smoking cessation support 1
• Aggressive cardiovascular risk management with statins and antiplatelet therapy 1
• Glycemic control with consideration of medications that have cardiovascular benefits 1

Management of Peripheral Arterial Disease (PAD)

• Evaluate the entire lower extremity arterial circulation with detailed visualization of below-the-knee and pedal arteries using color Doppler ultrasound, CT angiography, MR angiography, or intra-arterial digital subtraction angiography 1
• Consider urgent vascular imaging and revascularization for patients with ankle pressure <50 mmHg or ABI <0.5 1
• The aim of revascularization is to restore direct flow to at least one of the foot arteries, preferably the artery supplying the anatomical region of the wound 1
• Patients with signs of PAD and foot infection should be treated as a medical urgency, preferably within 24 hours 1
• Consider low-dose rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily in patients with symptomatic lower extremity arterial disease 1

Management of Diabetic Foot Infections

• Prompt recognition and treatment of infections is critical to prevent amputation 1
• Culture-directed antibiotic therapy should be initiated for infected wounds 2
• Surgical debridement of infected and necrotic tissue 2
• Patients with moderate to severe infections often require hospitalization and may need surgical intervention 1

Ulcer Management

• Reduce pressure from weight bearing on ulcers through appropriate offloading devices 2
• Regular debridement of non-viable tissue 1
• Treatment of infection with appropriate antibiotics 1
• Revascularization for ischemic ulcers 1
• Consider advanced wound healing therapies for non-healing ulcers 2

Multidisciplinary Care

• Establish a multidisciplinary team including endocrinologists, podiatrists, vascular surgeons, infectious disease specialists, and wound care specialists 2
• Multidisciplinary care is associated with lower major amputation rates compared to usual care 2

Cardiovascular Risk Management

• Aggressive cardiovascular risk management is essential as patients with diabetic foot ulcers and PAD have an overall 5-year mortality of approximately 50% 1
• Prescribe statins, which are associated with decreased mortality in patients with diabetes who undergo amputations 3
• Consider SGLT2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) to reduce the risk of heart failure hospitalization 1
• GLP-1 receptor agonists (liraglutide, semaglutide, or dulaglutide) are recommended in patients with type 2 diabetes and cardiovascular disease to reduce cardiovascular events 1

Monitoring and Follow-up

• Regular monitoring of high-risk patients, with more frequent assessments for those with previous ulcers or amputations 1
• Educate patients on self-monitoring techniques, especially those with LOPS 1
• Address recurrence prevention strategies, as recurrence after healing is estimated to be 42% at 1 year and 65% at 5 years 2

Prognosis and Mortality Considerations

• The 5-year mortality rate for individuals with a diabetic foot ulcer is approximately 30%, exceeding 70% for those with a major amputation 2
• After a major amputation, the one-year survival rate can be as low as 41.7% and five-year survival as low as 8.3% 4
• Early intervention is critical, as short time from first admission to amputation is associated with increased mortality 3