Diabetic foot ulcers (DFU) are common, complex and costly. Chronic hyperglycemia is associated with delayed wound healing and lower limb amputations. We performed a systematic review of literature looking for studies that assessed the impact of change in glycemic control on DFU healing.
Our search included key words such as ’glycemic control’, ’glycated hemoglobin (HbA1c)’, cross-linking them with text such as ’diabetic foot ulcer’, and ’wound healing’. We included published articles and studies in English with at least one component of observation or intervention that included effect of change in glycemic control and/or HbA1c on DFU healing; we excluded studies involving only DFU related amputations as outcome.
Six studies were identified- 1 randomized controlled trial (RCT), 2 observational studies, 1 pre-post study, 1 case report and 1 pooled analysis. All studies were heterogeneous in design, sample size, duration, patient characteristics, DFU characteristics, and end points or outcomes, including the manner in which glycemia was measured. While the RCT was inconclusive due to recruitment failure, the observational studies did show a relationship between wound healing and improvement in glycemic control. The pre-post study and case report described considerable improvement in healing rates of DFU that had been previously resistant to conventional care, after strictly controlling glycemia. The pooled analysis demonstrated that worsening glycemic control during DFU treatment significantly decreased the odds of wound healing.
Surprisingly, there exists a major gap of evidence with regards to whether prospectively lowering glycemic exposure improves DFU outcomes in patients with diabetes. The absence of a proper RCT, the heterogeneity of the existing studies, and the lack of consistency in their findings warrant a well designed prospective, randomized, controlled study to clearly establish whether aggressive glycemic control should be a standard in the management of diabetic foot ulcers.
M.D. Patil: None. U. Gunasekaran: None. J. La Fontaine: None. L. Meneghini: Advisory Panel; Self; Novo Nordisk Inc., Sanofi US. Consultant; Self; Sanofi US, Novo Nordisk Inc.. Advisory Panel; Self; Intarcia Therapeutics, Inc.. Other Relationship; Self; American Diabetes Association.