NON-healing leg wounds and ulcers are an ever-present worry for diabetics, but a new oral nutritional therapy medicine and a new stent bring hope. One encourages the body to heal itself, while the other will enable surgeons to provide non-invasive long-term solutions. Both tackle neuropathic and vascular diabetic problems.
Diabetic wounds are a big challenge for diabetics, says Patrizio Tatti, a leading diabetologist, and chief of diabetes and endocrinology at a hospital in Rome (ASL RMH). Roughly one-fourth of the diabetic population will have a non-healing wound. "And this has important social and economic consequences as this can lead to amputation," he says during a recent visit to Singapore.
"So we've to try to reduce the events. One of the objectives of diabetic cure is to reduce numbers of amputations. But even if you don't end with an amputation, having an ulcer is still a great problem as your work life and personal life are affected," says Prof Tatti.
Diabetics who don't monitor their condition take an average of 10 years to develop neuropathy, where the nerves that carry sensation from the legs to the brain lose their function and degenerate over time. "They can have a stone in the shoe and not know it, which can break their skin or bone and don't even feel it. And their feet are also more rigid unlike a normal foot that adapts," he explains.
What doctors have found is that there's some substance in the body that's crucial to closure of the wound. "Diabetics have a missing crucial protein in their body... and while their bodies create sugar, their bodies can't utilise it."
Abound is an oral medication that has compounds which can "simulate" the body's own natural healing process. It finalises the process of diabetic wound closure in neuropathic wounds (rather than vascular diabetic wounds).
Three key components in it are HMB, Arginine and Glutamine. "These are natural substances which occur in the body, and diabetics are mostly malnourished in the sense that their body lacks these critical substances," says Prof Tatti.
Because of its natural substances, it's administered as a "specific nutritional treatment" programme. "Medicine" within Western tradition, says Prof Tatti, are chemical substances that aren't created by the body, but in fact interferes with body function and can have unwanted effects.
Prof Tatti has done a retrospective of cases over the last 10 years, and a prospective study is being done. One of the recent cases he had treated was a patient with complete disarrangement of the bones in the feet, so much so that his feet didn't even look normal.
The patient had an ulcer and was hospitalised for four months with repeated courses of antibiotics. When the ulcer recurred after two months, he was treated with Abound, and within 14 days of treatment, with just one course of antibiotics, he had complete healing of the skin.
"The nutritional treatment doesn’t have an effect on diabetes itself, but only on the healing of the skin," explains Prof Tatti. Besides neuropathy, diabetic patients also risk having vascular problems.
Takao Ohki, chief of vascular surgery at Jikei University School of Medicine in Tokyo, says: "Most of the time, diabetics have their lower limbs amputated because of vascular problems, or poor circulation. Two-thirds of diabetics suffer that, while neuropathy makes up just one-third of the cause for amputations."
Poor circulation is due to blockage of arteries in the legs and happens most frequently in diabetics, although non-diabetics can experience it too. Up to 20 per cent of all adults over the age of 65 may be affected by Peripheral Arterial Disease (PAD).
There are two ways to treat this condition: One is through surgery where a bypass is done, and another is to insert a stent. "The problem with a bypass is that it's invasive surgery so it's less popular, and has more complications. With the stent, there is reblockage within three years," says Prof Ohki, who is also professor of surgery at Albert Einstein College of Medicine in New York.
A new stent has recently just been available, which has a special coating of drugs on it that will prevent this re-blockage. The Zilver PTX stent is the world's first drug-eluting stent for treating PAD in the superficial femoral artery (the largest artery in the leg).
"Awareness of PAD became more prevalent just about two to three years ago," he says, during a recent visit to Singapore. The risk factor in Singapore and Western countries is rising rapidly. Every day, at least two people in Singapore lose a foot or part of the lower leg through amputation due to PAD when blocked arteries prevent proper blood flow to muscles.
Symptoms of PAD include early stage numbness or cold feet. "People can't walk properly, or they limp, but it's often mistaken for joint pain and arthritis. Majority of patients tend to be diagnosed as having arthritis although sometimes it could include PAD," says Prof Ohki.
One way to ascertain PAD is to measure the blood pressure in the ankles. "It's the same as measuring the pulse in the hand, so you do it in the legs. A weakened pulse or an absent one in the foot indicates poor circulation which is intermittent claudication."
About half of diabetics who lose sensation in their legs (neuropathy) also have vascularity, he adds. Those who have both need to first treat blockage of arteries, he says. "The new stents are pretty remarkable as only about 10 per cent of it get reblocked, while reblockage happens to about 50 per cent of the conventional stents," says Prof Ohki.
In Singapore, approximately 700 lower limb amputations are performed on diabetic patients annually. Besides experiencing reduced quality of life and greater emotional and financial burdens, patients also face increased risk of mortality (about 10 per cent at the time of amputation and as high as 70 per cent within five years).
To find out about more about Abound, click here.
HMB (beta-hydroxy beta-methylbutrate), Arginine and Glutamine that are scientifically formulated to help build lean body mass
