Cost-effectiveness of clostridial collagenase ointment on wound closure in patients with diabetic foot ulcers: economic analysis of results from a multicenter, randomized, open-label trial

Diabetic Foot Ulcer Management and Treatment: An Overview of Published Patents

BACKGROUND

One of the most challenging effects of diabetes is diabetic foot ulceration (DFU). DFU may occur in up to one-third of individuals with diabetes mellitus (D.M.) at some point in their lives. The major cause of morbidity in D.M. patients is DFU. The length of treatment is difficult, and DFU recurrence is common.

OBJECTIVE

The most crucial element for the treatment and prevention of DFUs require a multidisciplinary approach. Patients who are at risk should be identified, depending on the type of risk, prophylactic actions etc. It is imperative to identify at-risk patients and take preventative measures accordingly.

METHOD

The at-risk diabetes-related foot ulcer was identified based on the risk category classification, while the foot ulcers were evaluated using Wagner's classification system.

RESULTS

Literature reported that patients with lower limb vascular insufficiency, loss of vibratory sensation, or protective sensation loss have an increased risk of developing foot ulcers. Proper categorization and therapeutic measures will be implemented after the DFU has been formed. The appropriate assessment and management of general health status should include glycemic control, the diagnosis and treatment of vascular disease, standard care for wounds, diagnosis, and infection treatments.

CONCLUSION

The review reflects the updated awareness of the treatment and management of DFU based on the current and past literature and patent analysis.

Comparison of healing effectiveness of different debridement approaches for diabetic foot ulcers: a network meta-analysis of randomized controlled trials

Objectives

The choice of the debridement method is very important for the healing of diabetic foot ulcers (DFUs), but the relative effectiveness of different debridement methods in the healing of DFUs remains unclear. This study conducted a network meta-analysis of the relative healing effectiveness of different debridement methods in patients with DFUs.

Methods

We performed a literature search in PubMed, Embase, and Cochrane Library from database inception up to 30 June 2023 for screening randomized controlled trials on the healing effectiveness of debridement in DFUs. Outcome measures included ulcer healing rate and ulcer area reduction rate. The Cochrane Risk Bias Tool, version 2.0, was used to assess the risk of bias in the included trials. R software was used for performing statistical analysis and GraphPad Prism was used for image plotting.

Results

A total of 19 randomized controlled trials were included, and 900 patients with DFUs were assessed in this analysis. The proteolytic fraction from the latex of Vasconcellea cundinamarcensis (P1G10) in enzymatic debridement showed the best ulcer healing rate (SURCA = 0.919) when compared with the standard of care (SOC) group, with a mean difference (MD) and 95% confidence interval (CI) of 1.40 (0.57, 2.36). Kiwifruit extract demonstrated the best effect on the ulcer area reduction rate (SURCA = 0.931), when compared with that in the SOC group, with an MD and 95% CI of 0.47 (0.27, 0.66).

Conclusion

Enzymatic debridement was superior to other debridement methods in terms of ulcer healing rate and ulcer area reduction rate in patients with DFUs. However, as the quality of the included trials is low, enzymatic debridement can be used as a candidate debridement method in addition to sharp-based debridement in clinical practice.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023441715.

3D scaffolds in the treatment of diabetic foot ulcers: New trends vs conventional approaches

Diabetic foot ulcer (DFU) is a serious complication of diabetes mellitus, affecting roughly 25% of diabetic patients and resulting in lower limb amputation in over 70% of known cases. In addition to the devastating physiological consequences of DFU and its impact on patient quality of life, DFU has significant clinical and economic implications. Various traditional therapies are implemented to effectively treat DFU. However, emerging technologies such as bioprinting and electrospinning, present an exciting opportunity to improve current treatment strategies through the development of 3D scaffolds, by overcoming the limitations of current wound healing strategies. This review provides a summary on (i) current prevention and treatment strategies available for DFU; (ii) methods of fabrication of 3D scaffolds relevant for this condition; (iii) suitable materials and commonly used molecules for the treatment of DFU; and (iv) future directions offered by emerging technologies.

The Effect of Kiwifruit Therapeutics in the Treatment of Diabetic Foot Ulcer

Diabetes mellitus is considered a silent disease with possible late chronic complications such as diabetic foot ulcer. This condition is managed by surgical debridement. To improve surgical outcome, some surgeons use proteolytic agents after surgery. Kiwifruit contains a type of proteolytic enzyme called actinidin that may play a role in the treatment of such complication. In the current study, we evaluate the role of kiwifruit extract in the treatment of diabetic foot ulcer. Eighteen diabetic foot ulcer patients were included in a randomized, double-blind clinical trial. The patients were divided randomly to control and experimental groups. Patients in the control group underwent daily wound dressing using base ointment (Eucerin). In the experimental group, we added kiwifruit extract to the standard wound dressing. Clinical data including general appearance of wound (according to recorded photographs before and after medical intervention) were analyzed using SPSS version 22. The mean wound area of the experimental group was significantly less than in the control group (P = .005) after 4 weeks of treatment. Comparison of the average of size difference, before and after the treatment in the experimental group and the control group, shows that kiwifruit can have a good impact on wound healing (P = .0001). In patients with diabetic foot ulcer, wound dressing using kiwifruit extract may help reduce time of treatment and may replace surgical debridement for some selected cases.

Skin Wound Healing Process and New Emerging Technologies for Skin Wound Care and Regeneration

Skin wound healing shows an extraordinary cellular function mechanism, unique in nature and involving the interaction of several cells, growth factors and cytokines. Physiological wound healing restores tissue integrity, but in many cases the process is limited to wound repair. Ongoing studies aim to obtain more effective wound therapies with the intention of reducing inpatient costs, providing long-term relief and effective scar healing. The main goal of this comprehensive review is to focus on the progress in wound medication and how it has evolved over the years. The main complications related to the healing process and the clinical management of chronic wounds are described in the review. Moreover, advanced treatment strategies for skin regeneration and experimental techniques for cellular engineering and skin tissue engineering are addressed. Emerging skin regeneration techniques involving scaffolds activated with growth factors, bioactive molecules and genetically modified cells are exploited to overcome wound healing technology limitations and to implement personalized therapy design.

Application of Solidago chilensis and laser improved the repair of burns in diabetic rats

Background

The repair of burns in diabetic patients is a clinical problem. It is relevant to study alternative therapies that can improve the healing process. Our aim was to investigate the effects of Solidago chilensis associated or not with laser on burns in diabetic rats.

Methods

The animals were divided in four groups (n = 30): C- without treatment; S– S. chilensis extract; L-laser irradiated; LS- laser and S. chilensis. In 7, 14 and 21 days samples were collected after the injury to structural, morphometric and molecular analysis.

Results

Our results demonstrate the association of S. chilensis and laser reduced the inflammatory infiltrate and favored the angiogenesis. In the groups treated only with laser or with the plant extract showed higher levels of VEGF. The low-level laser therapy (LLLT) promoted higher collagen I and reduction of collagen III. It was also observed higher MMP-2 activation and a decreasing of the active isoform of MMP-9 in the S, L and LS groups.

Conclusions

The treatments improved the repair of burns in diabetic rats, since it reduced the inflammatory infiltrate and favored the collagen organization presenting similar effects in the burn repair of the diabetics.

Talar Osteonecrosis After Subchondroplasty for Acute Lateral Ligament Injuries: Case Series

Talar osteonecrosis is a well-described phenomenon following talar neck fracture, but is a rarely described complication after procedures about the foot and ankle. Here we describe the clinical course of 5 cases of talar osteonecrosis following injection of calcium phosphate into the talus (subchondroplasty) with or without acute lateral ligament repair after acute lateral ankle ligament injuries performed at an outside institution. Practitioners should be aware of this potentially devastating complication. Future research is indicated to determine the safety and efficacy of subchondroplasty for the talus.

Fundamental aspects of the local approach to cutaneous ulcers

Ulcers or wounds can be classified as acute or chronic. Their treatment involves overall assessment of the patient and choice of suitable local therapy, and the appropriate indication and use of products. Technological progress in the field of wound treatment has increased rapidly. Constant updating, with emphasis on available scientific evidence, is necessary to offer the best approaches to patients with acute and chronic wounds. A qualitative analysis of literature was conducted to identify scientific publications that update the concepts involved in local wound treatment, to present some resources that can aid the healing process and describe the different types of dressings available. This review includes wound assessment using the acronym TIME (tissue, infection/inflammation, moisture balance and edge of wound), cleaning and debridement, infection/inflammation control, exudate control, dressing types and main indications.

Publicly Reported Wound Healing Rates: The Fantasy and the Reality

Significance: We compare real-world data from the U.S. Wound Registry (USWR) with randomized controlled trials and publicly reported wound outcomes and develop criteria for honest reporting of wound outcomes, a requirement of the new Quality Payment Program (QPP). Recent Advances: Because no method has existed by which wounds could be stratified according to their likelihood of healing among real-world patients, practitioners have reported fantastically high healing rates. The USWR has developed several risk-stratified wound healing quality measures for diabetic foot ulcers (DFUs) and venous leg ulcers (VLUs) as part of its Qualified Clinical Data Registry (QCDR). This allows practitioners to report DFU and VLU healing rates in comparison to the likelihood of whether the wound would have healed. Critical Issues: Under the new QPP, practitioners must report at least one practice-relevant outcome measure, and it must be risk adjusted so that clinicians caring for the sickest patients do not appear to have worse outcomes than their peers. The Wound Healing Index is a validated risk-stratification method that can predict whether a DFU or VLU will heal, leveling the playing field for outcome reporting and removing the need to artificially inflate healing rates. Wound care practitioners can report the USWR DFU and VLU risk-stratified outcome measure to satisfy the quality reporting requirements of the QPP. Future Directions: Per the requirements of the QPP, the USWR will begin publicly reporting of risk-stratified healing rates once quality measure data have met the reporting standards of the Centers for Medicare and Medicaid Services. Some basic rules for data censoring are proposed for public reporting of healing rates, and others are needed, which should be decided by consensus among the wound care community.

Update on management of diabetic foot ulcers

Diabetic foot ulcers (DFUs) are a serious complication of diabetes that results in significant morbidity and mortality. Mortality rates associated with the development of a DFU are estimated to be 5% in the first 12 months, and 5-year morality rates have been estimated at 42%. The standard practices in DFU management include surgical debridement, dressings to facilitate a moist wound environment and exudate control, wound off-loading, vascular assessment, and infection and glycemic control. These practices are best coordinated by a multidisciplinary diabetic foot wound clinic. Even with this comprehensive approach, there is still room for improvement in DFU outcomes. Several adjuvant therapies have been studied to reduce DFU healing times and amputation rates. We reviewed the rationale and guidelines for current standard of care practices and reviewed the evidence for the efficacy of adjuvant agents. The adjuvant therapies reviewed include the following categories: nonsurgical debridement agents, dressings and topical agents, oxygen therapies, negative pressure wound therapy, acellular bioproducts, human growth factors, energy-based therapies, and systemic therapies. Many of these agents have been found to be beneficial in improving wound healing rates, although a large proportion of the data are small, randomized controlled trials with high risks of bias.

Enzymatic debridement with collagenase in wounds and ulcers: a systematic review and meta-analysis

Enzymatic debridement with collagenase is a technique that is commonly used in clinical practice. This systematic review examines the effect of collagenase on all kinds of wounds, compared to an alternative therapy, on wound healing, wound bed characteristics, cost-effectiveness and the occurrence of adverse events. We conducted a systematic literature search on available literature in Cochrane databases, MEDLINE, EMBASE and CINAHL. Two investigators independently assessed the titles and abstracts of all randomised controlled trials obtained involving collagenase of all kinds of wounds based on inclusion criteria. Of the 1411 citations retrieved, 22 studies reported outcomes with the use of collagenase either for wound healing or wound debridement. Results support the use of collagenase for enzymatic debridement in pressure ulcers, diabetic foot ulcers and in conjunction with topical antibiotics for burns. However, studies presented a high risk of bias. Risk ratio of developing an adverse event related to collagenase versus the alternative treatment was statistically significant (for 10 studies, RR: 1·79, 95% CI 1·24-2·59, I2 =0%, P = 0·002). There is very limited data on the effect of collagenase as an enzymatic debridement technique on wounds. More independant research and adequate reporting of adverse events are warranted.

Comparative cost and clinical effectiveness of clostridial collagenase ointment for chronic dermal ulcers

Chronic dermal ulcers affect approximately 2.4-4.5 million people in the USA and are associated with loss of function, decreased quality of life and significant economic burden. Debridement is a critical component of wound care involving removal of nonviable tissue from chronic wounds to stimulate the granulation and epithelialization process. Clostridial collagenase ointment has been used as a method of wound debridement for more than 50 years and is currently the only enzymatic debriding ointment with US FDA approval. This review discusses the results of recent real-world studies that build upon the evidence demonstrating the clinical effectiveness, cost-effectiveness and safety of clostridial collagenase ointment across wound types and care settings.

Economic analysis and budget impact of clostridial collagenase ointment compared with medicinal honey for treatment of pressure ulcers in the US

Objectives

Pressure ulcer (PU) treatment poses significant clinical and economic challenges to health-care systems. The aim of this study was to assess the cost-effectiveness and budget impact of enzymatic debridement with clostridial collagenase ointment (CCO) compared with autolytic debridement with medicinal honey (MH) for PU treatment from a US payer/Medicare perspective in the hospital outpatient department setting.

Methods

A cost-effectiveness analysis using a Markov model was developed using a 1-week cycle length across a 1-year time horizon. The three health states were inflammation/senescence, granulation/proliferation (ie, patients achieving 100% granulation), and epithelialization. Data sources included the US Wound Registry, Medicare fee schedules, and other published clinical and cost studies about PU treatment.

Results

In the base case analysis over a 1-year time horizon, CCO was the economically dominant strategy (ie, simultaneously conferring greater benefit at less cost). Patients treated with CCO experienced 22.7 quality-adjusted life weeks (QALWs) at a cost of $6,161 over 1 year, whereas MH patients experienced 21.9 QALWs at a cost of $7,149. Patients treated with CCO achieved 11.5 granulation weeks and 6.0 epithelization weeks compared with 10.6 and 4.4 weeks for MH, respectively. The number of clinic visits was 40.1 for CCO vs 43.4 for MH, and the number of debridements was 12.3 for CCO compared with 17.6 for MH. Probabilistic sensitivity analyses determined CCO dominant in 72% of 10,000 iterations and cost-effective in 91%, assuming a benchmark willingness-to-pay threshold of $50,000/quality-adjusted life year ($962/QALW). The budget impact analysis showed that for every 1% of patients shifted from MH to CCO, a cost savings of $9,883 over 1 year for a cohort of 1,000 patients was observed by the payer.

Conclusion

The results of these economic analyses suggest that CCO is a cost-effective, economically dominant alternative to MH in the treatment of patients with PUs in the hospital outpatient department setting.

Comparative Effectiveness of Clostridial Collagenase Ointment to Medicinal Honey for Treatment of Pressure Ulcers

Objective: Compare enzymatic debridement using clostridial collagenase ointment (CCO) with autolytic debridement using medicinal honey in the hospital outpatient setting for treating pressure ulcers (PUs).

Approach: Retrospective deidentified electronic health records from 2007–2013 were extracted from the U.S. Wound Registry. Propensity score matching followed by multivariable analyses was used to adjust for selection bias and assess treatment effects comparing CCO-treated versus honey-treated PUs. Key outcomes included 100% granulation and epithelialization at 1 year.

Results: Five hundred seventeen CCO-treated PUs (446 patients) were matched to corresponding honey-treated PUs (341 patients). The majority of PUs were stage III (CCO 56%, honey 55%). CCO users had significantly fewer total visits (9.1 vs. 12.6; p < 0.001), fewer total selective sharp debridements (2.7 vs. 4.4; p < 0.001), and fewer PUs receiving negative pressure wound therapy (29% vs. 38%; p = 0.002) compared with honey.

Innovation: CCO-treated PUs were 38% more likely to achieve 100% granulation compared to honey-treated PUs at 1 year, p = 0.018. Mean days to 100% granulation were significantly lower for CCO-treated PUs (255 vs. 282 days, p < 0.001). CCO-treated PUs were 47% (p = 0.024) more likely to epithelialize at 1 year compared to PUs treated with honey. Mean days to epithelialization were significantly lower for PUs treated with CCO at 1 year (288 vs. 308 days; p = 0.011).

Conclusion: All stages of PUs treated with CCO achieved faster rates of granulation and subsequent epithelialization compared to PUs treated with medicinal honey as measured by real-world data collected in the hospital outpatient department care setting.

A synthetic leukotriene B4 receptor type 2 agonist accelerates the cutaneous wound healing process in diabetic rats by indirect stimulation of fibroblasts and direct stimulation of keratinocytes

AIMS

The synthetic leukotriene B₄ receptor type 2 (BLT2) agonist CAY10583 (CAY) accelerates wound healing in diabetic mice by promoting keratinocyte migration. However, its effects on fibroblast activity and granulation are unknown. We investigated the mechanisms by which CAY promotes wound healing.

METHODS

CAY was applied to wounds on streptozotocin-induced diabetic rats, and wound closure, granulation thickness, and epithelialization gaps were analyzed. BLT2 expression was examined by RT-PCR. Migration and proliferation were studied by scratch assays and MTS assays. Keratinocyte supernatants with CAY were applied to fibroblasts, and cytokines were measured by enzyme-linked immunosorbent assays.

RESULTS

CAY significantly accelerated wound healing in diabetic rats (CAY, 78.05±12.22% vs. control, 59.84±11.09%; p=0.0222), with increased re-epithelialization and granulation compared to controls. BLT2 was expressed in keratinocytes, but not in fibroblasts. Keratinocyte treatment with the CAY supernatant enhanced fibroblast proliferation and migration (fibroblast scratch closure: CAY, 75.95±4.09% vs. control, 49.69±4.49%; p<0.0001). CAY-treated keratinocytes exhibited increased TGF-β1 and bFGF expression.

CONCLUSIONS

CAY directly promotes keratinocyte migration and indirectly enhances fibroblast proliferation by increasing keratinocyte production of TGF-β1 and bFGF, accelerating wound closure. CAY is a promising pharmaceutical agent for diabetic wounds.

Therapeutic Effects of Static Magnetic Field on Wound Healing in Diabetic Rats

Objective. To investigate the effects of static magnetic field (SMF) on cutaneous wound healing of Streptozotocin- (STZ-) induced diabetic rats. Methods. 20 STZ-induced diabetic rats were randomly divided into two groups (10 in each group): diabetic rats with SMF exposure group which were exposed to SMF by gluing one magnetic disk of 230 mT intensity and diabetic rats with sham SMF exposure group (sham group). 10 normal Wistar rats were used as the control group. One open circular wound with 2 cm diameter in the dorsum was generated on both normal and diabetic rats and then covered with sterile gauzes. Wound healing was evaluated by wound area reduction rate, mean time to wound closure, and wound tensile strength. Results. The wound area reduction rate in diabetic rats in comparison with the control group was significantly decreased (P < 0.01). Compared with sham magnet group, diabetic rats under 230 mT SMF exposure demonstrated significantly accelerated wound area reduction rate on postoperative days 7, 14, and 21 and decreased gross time to wound closure (P < 0.05), as well as dramatically higher wound tissue strength (P < 0.05) on 21st day. Conclusion. 230 mT SMF promoted the healing of skin wound in diabetic rats and may provide a non-invasive therapeutic tool for impaired wound healing of diabetic patients.

Application of DCT-derived parameters for early detection of polyneuropathy in diabetic patients

Diabetic foot is one of the most severe complications of diabetes. Early diagnosis of this syndrome can ensure proper medical care and adequate treatment. Various image analysis methods can be used to speed up the diagnosis process, and automated diagnosis can be applied as a screening technique to reduce its cost. Introducing auxiliary diagnostic parameters may help to detect polyneuropathy or neuropathy, both of which often precede the appearance of diabetic foot syndrome. The present paper describes a study performed on a group of diabetic patients by analyzing plantar pressure distribution images. As part of this study, 2D discrete cosine transform (DCT) is computed for the forefoot and rearfoot regions of each diabetic subject in a group of 37 patients. Three new DCT-based parameters are introduced to help to detect polyneuropathy or at least indicate that the patient may have polyneuropathy without a time-consuming examination. The results indicate a certain relationship between these parameters and the presence of polyneuropathy. This information could be used in further diagnosis to prevent foot ulcers from developing in patients with diabetes.