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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   Dr. Satterfield is an Adjunct Associate Professor at the Western University College of Podiatric Medicine. She is a Fellow and President-Elect of the American College of Foot and Ankle Orthopedics and Medicine.

   Dr. Suzuki is the Medical Director of Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo, Japan.




References:

1. Backonja M, Glanzman RL. Gabapentin dosing for neuropathic pain: evidence from randomized, placebo-controlled clinical trials. Clin Ther 2003 Jan;25(1):81-104.
2. Ebbing M, Bonaa KH, Nygard O, et al. Cancer incidence and mortality after treatment with folic acid and vitamin B12. JAMA 2009 Nov 18;302(19):2119-26.
3. Ziegler D, Ametov A, Barinov A, et al. Oral treatment with alpha-lipoic acid improves symptomatic diabetic polyneuropathy: the SYDNEY 2 trial. Diabetes Care 2006; 29(11):2365-2370.
4. Ziegler D, Low PA, Boulton AJ, et al. Effect of 4-year antioxidant treatment with α-lipoic acid in diabetic polyneuropathy: the NATHAN 1 Trial. American Diabetes Association meeting Poster presentation, 2007.
5. Holick MF. Vitamin D deficiency. N Engl J Med. 2007 Jul 19;357(3):266-81.
6. MacKay D, Miller AL. Nutritional support for wound healing. Altern Med Rev. 2003 Nov;8(4):359-77.
7. Magalhães MS, Fechine FV, Macedo RN, et al. Effect of a combination of medium chain triglycerides, linoleic acid, soy lecithin and vitamins A and E on wound healing in rats. Acta Cir Bras. 2008 May-Jun;23(3):262-9.
8. Alleva R, Nasole E, Di Donato F, et al. Alpha-lipoic acid supplementation inhibits oxidative damage, accelerating chronic wound healing in patients undergoing hyperbaric oxygen therapy. Biochem Biophys Res Commun. 2005 Jul 29;333(2):404-10.
9. Robbins WR, Staats PS, Levine J, et al. Treatment of intractable pain with topical large-dose capsaicin: preliminary report. Anesth Analg. 1998 Mar;86(3):579-83.
10. Williams JZ, et al. Effect of a specialized amino acid mixture on human collagen deposition. Ann Surg 2002; 236(3):369-375.








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