Medication Summary
Many medications may have a role in the treatment of diabetes, the complications of diabetes, and the etiologies of diabetic ulcer. For example, hemorrheologic agents and antiplatelet agents are sometimes used in the management of underlying atherosclerotic disease. The role of aspirin, however, remains unclear.
Hemorrheologic Agents
Class Summary
Hemorrheologic agents such as pentoxifylline (Trental) improve intermittent claudication in approximately 60% of patients after 3 months. Cilostazol (Pletal) is an alternative hemorrheologic agent for patients who cannot tolerate pentoxifylline. [76] Cilostazol is contraindicated in patients with congestive heart failure. However, there is no conclusive evidence of any direct beneficial effect of either pentoxifylline or cilostazol on the healing of diabetic foot ulcers.
Pentoxifylline (Trental)
Pentoxifylline is indicated to treat intermittent claudication. It may alter rheology of red blood cells, which in turn reduces blood viscosity. Two to eight weeks of therapy may be required before symptomatic improvement occurs, and only about 60% of patients respond to this drug.
Cilostazol (Pletal)
Cilostazol is indicated to reduce symptoms of intermittent claudication, as indicated by an increased walking distance. It affects vascular beds and cardiovascular function and produces nonhomogeneous dilation of vascular beds, with greater dilation in femoral beds than in vertebral, carotid, or superior mesenteric arteries. Renal arteries were not found to be responsive to its effects. The mechanism of cilostazol involves inhibition of PDE, especially PDE III, and reversible inhibition of platelet aggregation. Patients may respond as early as 2-4 weeks after initiation of therapy, but treatment for as many as 12 weeks may be needed before a beneficial effect is experienced.
Antiplatelet agents
Class Summary
Antiplatelet therapy with aspirin or clopidogrel (Plavix) may be warranted in some cases for the prevention of the complications of atherosclerosis, although neither has a direct benefit in healing diabetic foot ulcers. Antiplatelet agents inhibit platelet function by blocking cyclooxygenase and subsequent platelet aggregation.
Clopidogrel (Plavix)
Clopidogrel selectively inhibits ADP binding to platelet receptor and subsequent ADP-mediated activation of glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation. It is indicated as antiplatelet therapy in some patients with atherosclerotic disease.
Aspirin (Bayer, Anacin, Empirin)
Aspirin inhibits prostaglandin synthesis, preventing formation of platelet-aggregating thromboxane A2. It may be used in low dose to inhibit platelet aggregation and to improve complications of venous stases and thrombosis. The recommended dose varies with indication, and, often, the literature is unclear on the optimal dosing.
Wound Healing Agents
Class Summary
Topically applied platelet-derived growth factors (PDGF) such as becaplermin gel (Regranex) have a modestly beneficial effect in promoting wound healing.
Becaplermin (Regranex)
Becaplermin gel 0.01% (Regranex), a recombinant human PDGF that is produced through genetic engineering, is approved by the US Food and Drug Administration (FDA) to promote healing of diabetic foot ulcers. [25] Regranex is meant for a healthy, granulating wound, not one with a necrotic wound base, and it is contraindicated with known skin cancers at the site of application.
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Diabetic ulcer of the medial aspect of left first toe before and after appropriate wound care.
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Diabetic ulcer of left fourth toe associated with mild cellulitis.
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Charcot deformity with mal perforans ulcer of plantar midfoot.
Tables
Category |
Examples |
Description |
Applications |
Alginate |
AlgiSite Comfeel Curasorb Kaltogel Kaltostat Sorbsan Tegagel |
This seaweed extract contains guluronic and mannuronic acids that provide tensile strength and calcium and sodium alginates, which confer an absorptive capacity. Some of these can leave fibers in the wound if they are not thoroughly irrigated. These are secured with secondary coverage. |
These are highly absorbent and useful for wounds having copious exudate. Alginate rope is particularly useful to pack exudative wound cavities or sinus tracts. |
Hydrofiber |
Aquacel Aquacel-Ag Versiva |
An absorptive textile fiber pad, also available as a ribbon for packing of deep wounds. This material is covered with a secondary dressing. The hydrofiber combines with wound exudate to produce a hydrophilic gel. Aquacel-Ag contains 1.2% ionic silver that has strong antimicrobial properties against many organisms, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. |
These are absorbent dressings used for exudative wounds. |
Debriding agents |
Hypergel (hypertonic saline gel) Santyl (collagenase) Accuzyme (papain urea) |
Various products provide some degree of chemical or enzymatic débridement. |
These are useful for necrotic wounds as an adjunct to surgical débridement. |
Foam |
LYOfoam Spyrosorb Allevyn |
Polyurethane foam has some absorptive capacity. |
These are useful for cleaning granulating wounds having minimal exudate. |
Hydrocolloid |
Aquacel CombiDERM Comfeel Duoderm CGF Extra Thin Granuflex Tegasorb |
These are made of microgranular suspension of natural or synthetic polymers, such as gelatin or pectin, in an adhesive matrix. The granules change from a semihydrated state to a gel as the wound exudate is absorbed. |
They are useful for dry necrotic wounds, wounds having minimal exudate, and clean granulating wounds. |
Hydrogel |
Aquasorb Duoderm IntraSite Gel Granugel Normlgel Nu-Gel Purilon Gel (KY jelly) |
These are water-based or glycerin-based semipermeable hydrophilic polymers; cooling properties may decrease wound pain. These gels can lose or absorb water depending upon the state of hydration of the wound. They are secured with secondary covering. |
These are useful for dry, sloughy, necrotic wounds (eschar). |
Low-adherence dressing |
Mepore Skintact Release |
These are various materials designed to remove easily without damaging underlying skin. |
These are useful for acute minor wounds, such as skin tears, or as a final dressing for chronic wounds that have nearly healed. |
Transparent film |
OpSite Skintact Release Tegaderm Bioclusive |
These are highly conformable acrylic adhesive film having no absorptive capacity and little hydrating ability, and they may be vapor permeable or perforated. |
These are useful for clean dry wounds having minimal exudate, and they also are used to secure an underlying absorptive material. They are used for protection of high-friction areas and areas that are difficult to bandage such as heels (also used to secure IV catheters). |
Risk category |
Definition |
Suggested follow-up |
|---|---|---|
0 |
No LOPS, no PAD, no deformity |
Annually |
1 |
LOPS ± deformity |
Every 3–6 months |
2 |
PAD ± LOPS |
Every 2–3 months |
3 |
History of ulcer or amputation |
Every 1–2 months |
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