Foot Ulcer and Lower Extremity Amputation in Diabetes: Clinical Implications

Highlights

Using DCCT/EDIC data, the effect of intensive glycemic control was compared with the effect of conventional glycemic control on the risk of lower extremity amputations (LEA) and diabetic foot ulcers (DFU). At 6-year follow-up, intensive glycemic control was associated with a reduced risk of DFU and LEA, although the risk of LEA was not significantly different between the two groups.
Risk factors associated with DFU included diabetic neuropathy and presence of albuminuria.
Intensive glycemic control may be associated with a reduced risk of diabetic foot ulcers.

Aim

Intensive glycemic control reduces the risk of renal, retinal, and neurological complications in type 1 diabetes (T1D), but it is unknown whether it reduces the risk of lower extremity complications.

We examined whether intensive versus conventional glycemic control among Diabetes Control and Complications Trial (DCCT) participants with T1D reduced the long-term risk of diabetic foot ulcers (DFU) and lower extremity amputations (LEA) in the Epidemiology of Diabetes Interventions and Complications Study (EDIC).

Methodology

DCCT participants (n = 1,441) completed an average of 6.5 years of intensive versus conventional diabetes treatment, after which 1,408 were enrolled in EDIC and followed annually for 23 years for occurrences of DFU. and LEA through physical examination.

Multivariable Cox proportional hazard regression models estimated the associations of DCCT treatment assignment and time-updated exposures with DFU or LEA.

Results

Intensive versus conventional glycemic control was associated with a significant risk reduction for all DFUs (hazard ratio 0.77 [95% CI: 0.60, 0.97]) and a risk reduction of similar magnitude but not significant for the first registered UPDs (0.78 [0.59, 1.03]) and first LEAs (0.70 [0.36, 1.36]).

In adjusted Cox models, clinical neuropathy, lower sural nerve conduction velocity, and cardiovascular autonomic neuropathy were associated with increased risk of DFU; estimated glomerular filtration rate <60 ml/min/1.73 m2, albuminuria and macular edema with increased risk of LEA; and any retinopathy and higher DCCT/EDIC time-weighted mean HbA1c with higher risk of both outcomes (P < 0.05).

Conclusions

Early intensive glycemic control decreases the risk of long-term DFU, the most important antecedent in the causal pathway of LEA.

Foot Ulcer and Lower Extremity Amputation in Diabetes: Clinical Implications

Foot ulceration and lower extremity amputation are significant complications of diabetes, adversely affecting quality of life and functional outcomes, highlighting the importance of preventive strategies and multidisciplinary management approaches in diabetic foot care.