Key Insights On Using Medications In Wound Care

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Other Considerations With Vitamins, Nutrition And Supplements In Wound Care

Q: What diet recommendations do you give your wound care patients?

A: Citing the old adage “You are what you eat,” Kazu Suzuki, DPM, CWS, notes most of his geriatric patients with wounds are not eating enough protein and calories to have optimal wound healing.

   He says the general guideline of daily dietary intake is “1.2 to 2 g of protein per kg,” which works out to be 60 to 100 g of protein for a 50 kg (110 lb) patient. Patients need to consume an appropriate amount of calories (30 to 35 calorie/kg or a minimum of 1,750 calories for a 50 kg patient) and water (30 to 35 mL/kg or a minimum of 1,750 mL) per day, according to a medical nutritionist who works with Dr. Suzuki.

   Kathy Satterfield, DPM, says the most important dietary consideration is keeping the blood sugar down, which keeps the neuropathy pain at bay. That means a diet of high protein and low carbohydrates, which she says does not appeal to most patients with diabetic neuropathy because they are usually obese. Dr. Satterfield says these patients usually eat high carbohydrate fare such as chips, fries and ice cream.

   When it comes to his patients with diabetic wounds, Lee Rogers, DPM, emphasizes good control of blood sugar with a proper, balanced diabetic diet. When the patient first presents with a wound, he says one should perform a nutritional assessment and lab work for albumin and prealbumin in order to help address any deficiencies.

Q: Do you recommend vitamins and other nutritional supplements?

A: “I do not buy into a mega-dose of vitamins being beneficial in keeping us healthy as we just do not have the clinical evidence to support it,” argues Dr. Suzuki.

   The only vitamin supplement that Dr. Suzuki recommends to his patients is vitamin D 2,000 IU once a day. He cites a growing body of clinical evidence that Americans are vitamin D deficient in general and the lack of adequate vitamin D is associated with various chronic diseases, autoimmune diseases and cancer.5

   While she does not know if vitamins are especially helpful, Dr. Satterfield notes vitamins B and E have been recommended for their potential benefits in wound healing.6,7 She traditionally recommends a good multi-vitamin to provide those vitamins that patients are missing.

   Dr. Satterfield says there is evidence that alpha lipoic acid works in facilitating wound healing.8 She says there is also evidence that capsaicin works as a topical for pain relief for the neuropathic pain that often affects these patients, adding that one should never apply it directly to a wound.9

   “Personally, I was shocked when I had a non-healing surgical wound years ago and although I was very heavy, I learned that I was malnourished and nutritionally deficient,” she recalls. “If it could happen to me, it could happen to my patients.”

   Dr. Rogers notes the study of vitamin C, zinc and amino acids in wound healing. “The real question is: does the patient require anything more than a multivitamin a day?” he asks. “I do not think there is any evidence to suggest otherwise.”

   Dr. Suzuki recommends protein supplements for all of his patients with wounds. He says Juven (Abbott Laboratories) is an orange drink that has been clinically proven to increase collagen deposits (wound healing) and the lean body mass in wound and cancer patients.10 Dr. Rogers notes that Abbott Laboratories is conducting the first randomized, controlled trial of a supplement (Juven) for diabetic foot wounds. He says this study is nearing conclusion.

   If patients do not like Juven, Dr. Suzuki recommends Ensure (Abbott Laboratories), a milkshake-like drink. Both supplements contain ample protein and calories, according to Dr. Suzuki. He has observed that liquid protein like juice and shakes are much easier to consume than solid protein like chicken breasts and boiled eggs.

   Overall though, Dr. Rogers says the problem with the nutritional supplement industry is that companies are not required to show efficacy in order to market their products. He says product claims for these supplements can be broad with no evidence or low quality evidence.

   “Supplements will not heal wounds but performing the basics of wound care will. Management of infection, revascularization, offloading and regular debridement is what heals wounds,” maintains Dr. Rogers.

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When it comes to patients with wounds, medications and supplements may help abate the pain and spur healing. These expert panelists discuss key considerations with the use of supplements and pharmaceuticals for wound pain and neuropathic wounds.

Q: What medications or supplements do you use for wound pain?

A: For Kazu Suzuki, DPM, CWS, appropriate wound debridement and applying a moist wound dressing are the most important keys in managing wound pain. For wound pain associated with debridement, Lee C. Rogers, DPM, suggests applying topical lidocaine gel or lidocaine soaked gauze. If this is insufficient, he says injecting an anesthetic in the periulcerative area or performing debridement in the OR can mitigate the pain.

   If the wound pain results from a dressing change, Dr. Rogers uses a non-adherent dressing such as Mepilex or Mepitel (Molnlycke) with Safetac silicone technology. He says an alternative would be soaking the dressing with an anesthetic prior to removal. For patients with pain due to VAC therapy (KCI) dressing changes, he notes one can turn off the suction, infiltrate the foam with lidocaine and let it set for a few minutes.

   Kathy Satterfield, DPM, says there is often a misperception that all wound patients are insensate but notes this is obviously not always the case. She treats patients’ wound pain “very aggressively,” often doing so in concert with physicians at pain clinics.

   If patients do not have pain relief with a hydrocodone/acetaminophen tablet (Vicodin, Abbott Laboratories) on a TID to QID basis, Dr. Satterfield refers them to a pain clinic. If the patient needs an additional modality such as a fentanyl patch for pain management, she defers to the pain management specialist.

   “It is good for referrals. It is good practice. It is just good medicine,” she notes.

   When it comes to pain medication, Dr. Suzuki uses an escalating approach that he learned from a pain management doctor. He will start with acetaminophen (Tylenol, McNeil) 1,000 mg four times a day. If this is not effective, Dr. Suzuki will consider hydrocodone/acetaminophen 5/500, 7.5/750, 10/660. If the pain continues unabated, he will consider oxycodone/acetaminophen (Percocet, Endo Pharmaceuticals) 5/325, 10/650.

   Sometimes Dr. Suzuki might prescribe extended-release oxycodone (Oxycontin, Purdue Pharma) if the patient has chronic pain and has been on opioid medications for a long time. If that is not enough, he will not hesitate to send patients to the pain management clinic as they may benefit from a transdermal pain patch or spinal injections of anesthetic/steroid medication.

Q: What drugs do you use to treat neuropathic pain?

A: Although there are several drugs that physicians may utilize for painful diabetic neuropathy (PDN), Dr. Rogers notes only two drugs have a FDA indication for this type of pain. These drugs are duloxetine (Cymbalta, Eli Lilly) and pregabalin (Lyrica, Pfizer). Dr. Suzuki mostly prescribes pregabalin 50 mg (starting with qhs and titrating up to TID) and duloxetine 30 mg (starting with QD for one week and then titrating up to 60 mg QD). He may add acetaminophen and opioid pain medications if the pain is severe but Dr. Suzuki says opioids should be a last resort.

   Dr. Rogers says other drugs that are commonly used without specific PDN indications are amitriptyline (Elavil, AstraZeneca), gabapentin (Neurontin, Pfizer), tramadol (Ultram, Ortho-McNeil) and oxycodone.

   Dr. Rogers notes that reviews of drug efficacies using the number needed to treat (NNT) can provide some guidance. He emphasizes caution when it comes to ensuring proper dosing. Dr. Rogers points out that dosing used in clinical trials is often higher than the dosing noted in the indications for the given drug, and dosing can vary depending upon what you are treating.

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