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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   For example, Dr. Rogers says the dosing for gabapentin in the Physicians Desk Reference is 100 to 300 mg/day but he cautions that this dosing is for the drug’s approved epilepsy indication, not painful neuropathy. Research has shown that one must prescribe gabapentin in excess of 1,800 mg/day (divided TID) in order for the medication to be effective for neuropathic pain, according to Dr. Rogers.1 Dr. Suzuki has found gabapentin frustrating given its gradual upward tapering and pain relief that can be hit or miss.

   Dr. Suzuki formerly prescribed tricyclic antidepressants for neuropathy but says the side effects can be harsh and intolerable for many patients. When it comes to painful diabetic neuropathy, Dr. Satterfield notes she has had less than 30 percent of patients achieving pain relief with amitriptyline. When she has combined this with acetaminophen, patients had 60 percent achieving pain relief at night. Dr. Satterfield notes that some physicians add diphenhydramine (Benadryl) to help patients with DPN get through the night.

   Although advances in medicine have gone beyond this “neuropathy pain cocktail” combination, Dr. Satterfield says this can still be “a good option” for patients who do not have good insurance and cannot afford the newer generation drugs.

   Dr. Satterfield reminds DPMs of the transient nature of diabetic neuropathy. She notes that it can be painful at times and patients can have no sensation from this at other times.

   “It is those painful episodes we have to treat,” maintains Dr. Satterfield.

Q: Do you have a supplement of choice for neuropathic pain?

A: Dr. Suzuki has found some success treating neuropathic pain adjunctively with Metanx (Pamlab), a supplement comprised of folic acid and vitamin B complex, which reverses the endothelial dysfunction and increases the nitric oxide release. He cites a recent study indicating increased cancer incidence and mortality after treatment with folic acid and vitamin B12.2 Although the study may not be completely applicable with Metanx, Dr. Suzuki says it is something to consider.

   Dr. Suzuki notes clinical evidence that some antioxidant supplements, such as alpha lipoic acid, may slow down the progression of diabetic neuropathy. The SYDNEY 2 trial showed that 600 mg of alpha-lipoic acid once a day PO improved neuropathic symptoms and deficits in patients with diabetic neuropathy as early as four weeks of treatment.3 The NATHAN 1 trial also showed that alpha-lipoic acid was well-tolerated and improves some neuropathic deficits and symptoms in mild to moderate neuropathy.4

   Dr. Satterfield has used “the whole gamut of supplements” for painful diabetic neuropathy. While she believes some supplements have a positive effect, she calls for more randomized, controlled studies to prove their efficacy. To date, Dr. Rogers says no randomized, controlled trial has shown dietary supplements to be effective for neuropathic pain.

   “I refuse to use a dietary supplement for neuropathic pain and consider it cruel if it were the sole treatment,” says Dr. Rogers.

   Furthermore, Dr. Rogers notes the etiology of diabetic neuropathy is not a vitamin deficiency but likely a hypoxic nerve injury from microvascular damage. He compares diabetic neuropathic pain to the pain of the foot falling asleep and waking up.

   “Now imagine that the only treatment your doctor offered you for this pain was a vitamin. How satisfied would you be with this treatment?” he asks. “There is also a lack of sound evidence to use supplements for non-painful sensory neuropathy but it probably does no harm to use them adjunctively.”

   Dr. Rogers is an Associate Medical Director of the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles. He is a Fellow of the American College of Foot and Ankle Orthopedics and Medicine.

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