SVS, APMA, and SVM Publish First-Ever Guidelines for Treating Diabetic Foot

February 3, 2016—The Society for Vascular Surgery (SVS), the American Podiatric Medical Association, and the Society for Vascular Medicine have collaboratively published their first-ever set of clinical practice guidelines for treating the diabetic foot, based on a meta-analysis of the available literature. 

The guidelines, “The Management of the Diabetic Foot,” were developed after 3 years of study and were published in the Journal for Vascular Surgery (2016;63:3S–21S). Additionally, the clinical practice guidelines will be available soon through the free SVS iPG app, which will be available through Google Play and the App Store. Anil P. Hingorani, MD, is the lead author for the SVS writing group that researched and wrote the guidelines; that group operates under the SVS Document Oversight Committee. 

The announcement noted that one of the findings physicians may find surprising was the importance of the total contact cast in the treatment of plantar diabetic foot ulcers, which the committee found was supported by robust data. Off-loading takes all direct pressure off the ulcer through use of a cast; a nonremovable, fixed-ankle walking boot; or similar treatment. Dr. Hingorani stated, “Total contact casting is so underutilized. I think some surgeons may find it surprising and it may raise a few eyebrows. Many surgeons are not aware of how strong the evidence is for TCC. It is not new but not widely understood or implemented.”

According to the societies, the guidelines will help identify which patients are at high risk, and they include a review of the various types of wound care for the diabetic foot. They also summarize and grade the best available evidence and set some protocols to help treat food ulcers. The guidelines will need to be implemented into training programs and will be updated with new evidence periodically.

In the SVS announcement, Dr. Hingorani explained that with diabetes being a major worldwide problem and with little data on treatments, the need for detailed, diabetic foot clinical guidelines from multiple disciplines was great. He added, “There has been very little level 1 randomized data looking at treatment. This is such a major problem in the United States and worldwide, but there has been so little written information and no guidelines combining the various viewpoints of these specialties.” 

The writing group members used the GRADES—Grades of Recommendation Assessment, Development, and Evaluation System—to rate the quality of evidence and the strength of recommendations. The Mayo Clinic in Rochester, Minnesota, provided meta-analysis assistance.

The committee synthesized the points of view of three different medical professions by researching one another’s treatment protocols. For example, vascular surgeons and vascular medicine specialists read literature from podiatry and vice versa, and all participants concentrated on infectious disease control and guidelines, a large component of the finished document. 

Dr. Hingorani noted that collaboration was key. He stated, “We had multiple disciplines looking at the problem to bring the best information from each field to develop the guidelines.” However, only limited “high-quality evidence” was available for many of the critical questions, noted Dr. Hingorani. 

“This is an important contribution by the SVS since the new guidelines can improve patient care, save lives and limbs, and reduce costs,” concluded Dr. Hingorani.