What is the recommended treatment for diabetic arthritis?

Treatment of Diabetic Arthropathy

The recommended treatment for diabetic arthritis is a non-removable knee-high device to immobilize and offload the foot, which promotes disease remission and prevents deformity progression in patients with active Charcot neuro-osteoarthropathy. 1

Understanding Diabetic Arthropathy

Diabetic arthropathy, particularly Charcot neuro-osteoarthropathy (CNO), is an inflammatory process in persons with peripheral polyneuropathy that results in injury to bones, joints, and soft tissues. It most commonly affects the foot and ankle in people with diabetes mellitus, causing fractures, dislocations, and fracture-dislocations that can lead to significant deformity. 1

Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Clinical examination is the primary method for detecting arthritis, which may be confirmed by ultrasonography 1
• If MRI is unavailable or contraindicated, consider nuclear imaging scan (scintigraphy), CT scan, or SPECT-CT to support the diagnosis 1
• Regular measurement of skin temperature differences between affected and unaffected limbs helps monitor disease activity 1
• Do not rely on blood tests like CRP, ESR, white blood count, or alkaline phosphatase to diagnose or exclude diabetic arthropathy 1

Treatment Algorithm

First-line Treatment:

• Use a non-removable knee-high device to immobilize and offload the foot 1
• Total contact cast is the preferred option for active Charcot neuro-osteoarthropathy 1
• A knee-high walker rendered non-removable can be considered as a second choice 1
• Treatment should begin as soon as possible once the diagnosis is considered 1

Adjunctive Measures:

• Use assistive devices to reduce weight-bearing on the affected limb 1
• Consider vitamin D and calcium supplementation during the fracture healing phase 1
• Do NOT use bisphosphonates (alendronate, pamidronate, zoledronate), calcitonin, PTH, methylprednisolone, or denosumab as treatment 1

Monitoring:

• Assess disease activity at 1-3 month intervals until remission is achieved 1
• Consider temperature measurement, clinical edema, and imaging when determining if active Charcot neuro-osteoarthropathy is in remission 1

Surgical Intervention:

• Consider surgical intervention in cases with joint instability, deformity with high risk of ulceration, or pain that cannot be sufficiently stabilized with conservative treatment 1

Prevention of Re-activation

After remission is achieved:

• Provide footwear and/or orthoses that accommodate and support the foot/ankle shape 1
• For patients with deformity and/or joint instability, use below-the-knee customized devices for additional protection 1

Special Considerations for Diabetic Patients with Inflammatory Arthritis

For patients with diabetes who also have inflammatory arthritis (such as rheumatoid arthritis):

• Start with oral small molecules (OSMs) other than methotrexate rather than TNF inhibitor biologics 1
• Consider methotrexate as the anchor drug for treatment of inflammatory arthritis, unless contraindicated 1
• Monitor glycemic control regularly, as corticosteroid use in rheumatoid arthritis can lead to hyperglycemia 2
• Be aware that certain DMARDs like hydroxychloroquine, methotrexate, and TNFα antagonists may improve glucose metabolism 3

Common Pitfalls to Avoid

• Do not use below-the-ankle offloading devices (e.g., surgical shoes, postoperative sandals) as they provide inadequate immobilization 1
• Avoid continuing antibiotics for the entire time a wound remains open rather than until infection resolves 4
• Be aware that patients with diabetes have a significantly higher risk of infection after total joint arthroplasty 5
• Do not rely solely on HbA1c levels to predict the risk of infection after total joint arthroplasty 5

By following this treatment algorithm and considering these special factors, the management of diabetic arthropathy can be optimized to improve outcomes and prevent complications.