SD Symposium-Diabetes (1-5

SD1-1

OVERVIEW AND PATHOPHYSIOLOGY OF DIABETIC PERIPHERAL NEUROPATHY

MING-HONG CHANG

Neurological Institute, Taichung Veterans General Hospital

Objective: To review the prevalence and possibly risk factors for diabetic peripheral neuropathy without pain (DPN) and diabetic peripheral neuropathy with pain (DPNP) in the world and Taiwan

Methods: Based on Medical publications concerning DPN and DPNP, we search for the related papers.

Results: We will present the available studies concerning the prevalence of DPN and DPNP and discussing the associated risk factors and possible pathophysiology, including biochemistry and related diseases.

Conclusions: The prevalence of DPN and DPNP is lower among Chinese diabetes patients, as compared with those in Western countries. Biochemical studies for DPN and the risk factors remain controversial and un-certain in pathophysiology; however, we will try to discuss each possible factor causing DPN or worsening the neuropathy.

SD1-2

TREATMENT OF DIABETIC PERIPHERAL NEUROPATHIC PAIN IN TAIWAN

SUN WEI-ZEN

Section of Pain Management, Department of Anesthesiology, National Taiwan University Hospital

1. DPN pregabalin duloxetine DPNP 2. TCAs DPNP 3. DPNP 4. DPN

SD1-3

DIAGNOSTIC TOOL AND EDUCATION OF DIABETIC PERIPHERAL NEUROPATHY

150 (Diabetic Peripheral Neuropathy,DPN) DPN 30% 20~30% (DiabeticPeripheral Neuropathic Pain, DPNP) DPN 2 DPN 1 5 DPN DPN 128Hz 10 DPN 48 DPN (Diabetes Self-Management Education,DSME) ( ) : (SDM) (DSME)

SD2-1

DM COMPLICATION: CV RISK AND EVENT. (MI, STROKE)

MING-CHIA HSIEH

Diabetes e institute, Changhua Christian Hospital, Taiwan

Patients with diabetes are at higher risk for cardiovascular diseases (CVDs) including myocardial infarction and stroke as compared with non-diabetic people. Cardiovascular diseases also remain the leading cause of morbidities and death in patients with diabetes, highlighting the importance of prevention and treatment of CVDs. Blood pressure control have been proved to reduce CVDs in patients with diabetes. However, the idea goal of blood pressure control remained controversy for diabetes. Statin therapy decreased the risk of CVDs in patients with diabetes.

Glycemic control is the cornerstone of diabetes management. Glucose lowering therapy to reach with diabetes. The effect of glucose lowering on CVDs by anti-diabetic agents seems to be uncertain. Since 2008, the Food and Drug Administration has required demonstration of CV safety for all new medications developed for the glycemic management of diabetes. Several randomized controlled trials involving around 60,000 participants have been completed so far and have demonstrated the CV safety of dipeptidyl peptidase 4 inhibitors (saxagliptin, alogliptin and sitagliptin), glucagonlike peptide-1 receptor agonists (lixisenatide, liraglutide and semaglutide) and a sodium-glucose co major CV events (CV death, nonfatal myocardial infarction, and nonfatal stroke). In addition, one trial compared and contrasted cautiously given the differences in patient populations and trial designs.

Comprehensive CV risk management is important for patients with diabetes. Glycemic control, blood pressure control and lipid lowering could reduce the risk of CVDs. Patients with diabetes are heterogeneous, so patient-centered and individual therapy should be given.

SD2-2

TIME FOR NEW FORMS OF INSULIN?

CHIA-HUNG LIN

Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital

Although a basal–bolus regimen with insulin analogs enables many patients to achieve their glycemic targets, issues associated with variability of action, and an action profile requiring strict administration timing, can reduce the likelihood of attaining good control. Insulin Degludec (IDeg) is an ultra-long acting insulin with a half-life of more than 24 h and a duration of action of more than 42 h. IDeg forms soluble and stable dihexamer in the pharmaceutical formulation with the help of phenol and zinc. IDeg is a once-daily basal insulin that provides a duration of action beyond 42 hours. It is important for people with type 1 and type 2 diabetes to establish a routine for insulin treatment. But for children and adolescents, whose daily routine can vary substantially, the precise injection time is IDeg to have one-fourth glycemic variability as compared to insulin glargine (IGlar) U100 at steady state concentration. This translates into up to 50% lower risk of hypoglycemia, especially nocturnal hypoglycemia as seen in various clinical trials. Owing to the preserved pharmacokinetic properties of may make IDeg a very useful option for patients and their caregivers.

SD2-3

INSULIN AND INCRETINS: THE PERFECT PARTNERSHIP?

YI-SUN YANG

Division chief of endocrinology and metabolism, Chung-Shan Medical University Hospital.

Patients with type 2 diabetes frequently do not reach HbA1c targets. Professional society guidelines recommend initial therapy with metformin, followed by intensification with any of cost, and preference. Because of the chronic, progressive nature of type 2 diabetes, many patients require insulin therapy. Basal insulin analogs are recognized as an effective method of achieving and maintaining glycemic control for patients with type 2 diabetes. However, the progressive nature of the disease means that some individuals may require additional ways to maintain their glycemic acting insulin to cover postprandial glucose excursions that are not targeted by basal insulin. However, intensive insulin regimens are associated with a higher risk of hypoglycemia and weight gain, which can contribute to a greater burden on patients.

GLP-1 RAs provide multiple potential advantages when combined with insulin. GLP-1 RAs produce robust HbA1c reduction stimulating endogenous insulin secretion and inhibiting the inappropriate postmeal glucagon response in a glucose-dependent manner. These agents have a low hypoglycemia risk as a result. GLP-1 RAs promote weight loss in part through signaling in appetite centers of the hypothalamus. The combination of basal insulin with a glucagon-like peptide-1 (GLP-1) mimetic is a potentially attractive solution to this problem for some patients with type 2 diabetes.

SD2-4

CARDIOVASCULAR OUTCOMES WITH ANTIHYPERGLYCEMIC THERAPY

1,2 KAI-JEN TIEN

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; 2Department of Senior Citizen Service Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan

The increased risk of cardiovascular disease in type 2 diabetic patients has been known for decades. However, until recently the cardiovascular (CV) impact of glucose lowering strategies has of glycemic control upon CV outcomes, as well as the CV effects of glucose management with newer antihyperglycemic agents. Dipeptidyl peptidase-4 (DPP4) inhibitors, glucagon-like peptide-1 (GLP1) analogs and sodium-glucose cotransporter 2 (SGLT2) inhibitors are relatively new therapies for the treatment of type 2 diabetes mellitus. Given the high prevalence of cardiovascular complications in patients with type 2 diabetes and recent concerns questioning CV safety of newer antidiabetic medications, cardiovascular safety of these medications requires evaluation.

Multiple CV safety trials designed to meet regulatory requirements for CV safety of antihyperglycemic medications have been initiated. The results of several completed CV outcomes in patients with type 2 diabetes, particularly in individuals at high CV risk. Important differences have been noted with respect to heart failure outcomes within the DPP4 inhibitor class, and thus far outcomes. Robust safety related information from trials designed to assess the CV effects of diabetes therapies will permit the incorporation of outcomes-based evidence into the formulation of diabetes care guidelines.

Based on review of the present evidence, these 3 classes of antihyperglycemic therapies have and EMPA-REG OUTCOME trials indicate that liraglutide and empagliflozin have cardiovascular

SD2-5

WHAT’S NEW FROM UPDATED TREATMENT ALGORITHM?

MEI-YUEH LEE

Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Taiwan, R.O.C. Division of Endocrinology and Metabolism , Department of Internal Medicine, Kaohsiung Medical University Chung Ho Memorial Hospital, Taiwan, R.O.C .Department of Medicine, Kaohsiung Medical University, Taiwan, R.O.C.

The goals in caring for patients with diabetes mellitus are to eliminate symptoms and to prevent, or at least slow, the development of complications. Microvascular (ie, eye and kidney disease) risk reduction is accomplished through control of glycemia and blood pressure; macrovascular (ie, coronary, cerebrovascular, peripheral vascular) risk reduction, through control of lipids and hypertension, smoking cessation, and aspirin therapy; and metabolic and neurologic risk reduction, through control of glycemia.Type 2 diabetes care is best provided by a multidisciplinary team of health professionals with expertise in diabetes, working in collaboration with the patient and family. Management includes self-monitoring of blood glucose (SMBG), regular monitoring for complications and laboratory assessment. Ideally, blood glucose should be maintained at near-normal levels (preprandial levels of 90-130 mg/dL and hemoglobin A1C [HbA1c] levels < 7%). However, focus on glucose alone does not provide adequate treatment for patients with diabetes mellitus. Treatment involves multiple goals (ie, glycemia, lipids, blood pressure).Early initiation of pharmacologic therapy is associated with improved glycemic control and reduced long-term complications in type 2 diabetes. Drug classes used for the treatment of type 2 diabetes include the following: biguanides, sulfonylureas, meglitinide derivatives, alpha-glucosidase inhibitors, thiazolidinediones (TZDs), glucagonlike peptide–1 (GLP-1) agonists, dipeptidyl peptidase IV (DPP-4) inhibitors, selective sodium-glucose transporter-2 (SGLT-2) inhibitor, insulins, amylinomimetics, bile acid sequestrants, and dopamine agonists.

Recommendations for the treatment of type 2 diabetes mellitus from the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) place the patient's condition, desires, abilities, and tolerances at the center of the decision-making process. The EASD/ ADA position statement contains 7 key points: 1. Individualized glycemic targets and glucose-lowering therapies 2. Diet, exercise, and education as the foundation of the treatment program 4. After metformin, the use of 1 or 2 additional oral or injectable agents, with a goal of minimizing adverse effects if possible 5. Ultimately, insulin therapy alone or with other agents if needed to maintain blood glucose control 6. Where possible, all treatment decisions should involve the patient, with a focus on patient preferences, needs, and values 7. A major focus on comprehensive cardiovascular risk reduction

SD2-6

GESTATIONAL DIABETES MANAGEMENT AND NICE GUIDELINE RECOMMENDATION

ANNE DORNHORST, M.D.,

Consultant Physician & Professor of Practice Imperial College London; Department of Medicine; Imperial College Healthcare NHS Trust

Pregnancy is associated with temporary changes in maternal metabolism which include a decrease in maternal fasting glucose concentrations as gestation progresses and an increase in postprandial glucose concentration as tissue sensitivity to insulin decreases. The maintenance of glucose tolerance in pregnancy requires a two- to three-fold increase in postprandial maternal insulin secretion by the beta-cells. Glucose intolerance develops in women unable to compensate for the metabolic changes associated with pregnancy. Gestational diabetes tends to occur from the 24th week of pregnancy. pregnancy symptoms, but may include increased thirst and frequent urination. Risk factors for GDM include advanced maternal age, obesity, family history (in particular maternal history) and non-white racial/ethnic origin. Physical activity is regarded as a protective factor and may delay or prevent the development of GDM and prevent complications to the foetus. In most cases of gestational diabetes, blood glucose levels can be controlled through a healthy diet, gentle exercise and blood glucose monitoring. In some cases, insulin or oral medication may also be prescribed. Gestational diabetes normally disappears after giving birth. However, women who have been previously diagnosed with GDM are at higher risk of developing GDM in subsequent pregnancies and T2DM later in life. Babies born to mothers with gestational diabetes also have a higher risk of developing T2DM in their teens or early adulthood.

SD3-1

TAIWAN DIABETES REGISTRY STUDY: AN INTRODUCTION AND PRELIMINARY REPORT

Despite a great efforts and advocates been introduced and implemented in promoting diabetes care, many diabetes patients are remained suboptimal controls. In Taiwan, two surveys in 2006 and 2011 commissioned by the Bureau of Health Promotion, Department of Health, ROC (Taiwan), and the Taiwanese Association of Diabetes Educators (TADE) showed that target achievement with respect to glucose, blood pressure and lipid control in diabetic patients were still suboptimal. In several countries and areas, including Sweden, Denmark, Australia, and Hong Kong, national diabetes registers are established as part of a quality improvement program of diabetes care. It has been shown by several studies that diabetes registry projects can help several issues in diabetes managements, including survey of epidemiology, and genetics, clinical presentations, diabetic and its related and associated complications, medication administration, and long term outcome. To further understand the care conditions in the patients with diabetes in this country, the Diabetes Association of R.O.C. (Taiwan) launched the Taiwan Diabetes Registry Study since 2015, October. This study is an observational study without additional intervention, and approved by join IRB in Taiwan. It will continuously enroll diabetic patients from 2015, Oct 1 to 2018, Jun 30, and follow period will be end until 2018, Dec 31. The diabetic patients ever enrolled into the quality control study by Taiwan Association of Diabetes Educators in 2006 and 2011, type 1 diabetic patients , and newly diagnosed type 2 diabetic patients are to be recruited. After obtaining the signed informed consent forms, the clinical information and various disease-related medical records of the patients are registered on the network. Then, at least one annual follow-up information will be re-registered yearly until 2018. In the web-based platform of Taiwan Diabetes Registry Study, the personal information (height, weight, blood pressure, waist and hip circumference, family history and history of cardiovascular disease), living habits (smoking, drinking, diet and activity level), the lab tests (lipids, blood glucose, HbA1c, renal and liver function), foot assessment, macrovascular and microvascular complications of diabetes, self-management status, and hospital admission history, etc., are recorded. In each registration, the patients also require completion of some questionnaires, such as Patient Health Questionnaire (PHQ-9), EQ-5D, etc. In this study, at present, a total of 95 diabetes health promotion institutes have given their permit to participate the diabetes registry study. Among them, 26 sites are distributed in north Taiwan, 48 in central Taiwan, 18 in south Taiwan and 3 in east Taiwan. Until Sep 30, 2016, a total of 2728 diabetic patients, including 847 who previously participated the quality control study by Taiwan Association of Diabetes Educators in 2006 and 2011, 595 type 1 diabetic patients , and 1286 newly diagnosed type 2 diabetic patients had been enrolled. For the 847 patients (aged 66.9 11.3 yrs; male 50.6% ) who previously participated the quality control study by Taiwan Association of Diabetes Educators in 2006 and 2011, 32.2% of patients had an A1c value less than 7%, 63.2% with a LDL-C level less than 100mg/dL, 30.4% with

a BP less than 130/80mmHg. For the newly diagnosed type 2 diabetic patients (aged 54.0 13.7 yrs; male 57.4%), 36% of patients had an A1c value less than 7%, 44% of with a LDL-C level less than 100mg/dL, 66.6% of patients had a BP less than 140/90mmHg. It is hoped that the rich dataset of Taiwan Diabetes Registry Study will provide an opportunity to address numerous issues of relevance to clinicians and patients, including assessments of associations between patient characteristics and diabetes management factors with outcomes.

SD3-2

BIOBANK IN REGISTRY STUDY

CHEN-YANG SHEN, FU-TONG LIU

Taiwan Biobank, Academia Sinica, Taiwan

The Taiwan Biobank (TWB) is establishing a scientific infrastructure that is accessible to biomedical researchers to increase our understanding of the relationships among genetics, environment, diet, and the etiology/progression of diseases. This effort is based on the recruitment and monitoring of a cohort of 200,000 individuals from the general Taiwanese population with no history of cancer and another 100,000 patients with chronic diseases of public health importance. TWB aims to improve the health of future generations and facilitate genomic research in Taiwan. The progressive elucidation of risk factors and of the molecular pathogenesis of disease will both improve disease prevention and facilitate the development of individualized prevention and therapy. Currently, more than 80,000 participants have been recruited, and >1,800,000 tubes of specimens have been collected. Staring from Sep, 2014, TWB has released both information and specimen to the public, and more than 100 studies have applied for these for in-depth research. In addition to the ongoing establishment of recruitment centers throughout Taiwan, TWB is currently focusing on disease gene mapping. A populationspecific reference of whole-genome genotyping, more than 20,000 whole-genome genotypings and and largest publically available Asian reference cohort. Through this study, the TWB has released the largest genome-wide genotype statistics for Han Chinese, providing appropriate statistical power to detect susceptibility variants, and the publicly accessible web-based calculation platform, Taiwan View, has been built to carry out genetic study using current control data.

SD3-3

PRECISION MEDICINE USING REGISTRY DATA

U-C YANG

Institute of Biomedical Informatics, National Yang-Ming University, Taiwan, R.O.C.

OBJECTIVE Most diseases have different subtypes. Different subtypes may have different responses to the same treatment. Therefore, it is important to identify the subtypes and give the right treatment for a given subtype. Precision medicine aims to classify diseases into subtypes based on a biomarker or a group of biomarkers (i.e. a bio-signature). To reach this goal, it is essential to integrate all types of information into a knowledge network. Data mining approaches can then be used to identify candidate bio-signatures for further studies.

MATERIAL AND METHODS The clinical informatics and management system (CIMS) has 4 subsystems, in which 3 of them have been used to establish a disease registry. The Clinical Study Information System (CSIS) can be used to collect clinical information; the Specimen Tracking and Management System (STAMS) can be used to record the storage location; the Global Unique IDentifier (GUID) can be used to integrate the clinical information and the high throughput data derived from bio-specimens. Both CSIS and STAMS can be deployed in a single sign-on portal. In other words, registry manager may switch between CSIS and STAMS without further login in this portal environment.

RESULTS The clinical and microarray data of breast cancer obtained from public repository were used to mimic a disease registry. The clinical data were stored in CSIS and the early phase study subjects can be selected by querying the CSIS. The microarray data of these patients were retrieved and normalized to one another. A gene expression threshold was optimized for each gene in order to separate patients into high and low expression groups, respectively. Those genes, which have a significant survival difference between the high and low expression groups, were identified as candidate biomarkers. Some of the pair-wise combination of these candidate biomarkers showed synergistic effects. In other words, such gene pairs can be used to identify a group of patients that have a poor 5-year survival rates.

CONCLUSIONS Gene expression bio-signatures can be used to classify a disease into subgroups. The functions of these genes may lead to the discovery of a disease mechanism. Such mechanism is the basis to translate genomic observation into a therapeutic treatment. If a treatment of the most severe subgroup can be found, the bio-signature becomes a companion biomarker for this particular disease subgroup. Taken together, companion biomarker makes disease diagnosis and treatment more

SD4-1

AN UPDATE ON DIABETES KIDNEY DISEASE

PROFESSOR WASIM HANIF MBBS, MD, FRCP

Professor of Diabetes & Endocrinology University Hospital Birmingham UK

OBJECTIVE Diabetes Nephropathy affects up to 40% of diabetes individuals this lecture is a scholastic update of this area. It covers the following:

dose adjustments with medications

The various sections are presented in details with up to date evidence to comprehensively cover this challenging area. The challenges of managing DKD both in terms of diabetes and other related issues are discussed with supporting evidence.

SD4-2

DIABETES MELLITUS AND DEMENTIA

1,2,3 Y-H, YANG

1Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; 2Department of Master’s Program in Neurology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; 3Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan

A growing body of clinical and epidemiological research suggests that two of the most common diseases of aging, type 2 diabetes (T2DM) and Alzheimer disease (AD), are linked. This linkage may be appreciated with some prevalence studies.

Over the last 25 years, many countries have seen in- creases in obesity, T2DM, and hypertension, all of which have been linked to an increase in dementia risk. However, at the same time, there have been important changes in treatments for these cardiovascular risk factors, including more widespread and intensive medication treatments

These improvements in cardiovascular risk factor control have helped cut these disease related complications and have likely the important ‘spillover’ benefits for brain health and the risk for cognitive decline and dementia during controlling these risk factors through drug and non-drug treatments.

AD, the most common cause of dementia, is a progressive and fatal neurodegenerative disorder in which certain types of neurons in particular brain regions degenerate, resulting in severe neuronal tangles (NFTs). This advancing pathology is believed to underlie the clinical presentation of memory cognitive functions. SPs are the extracellular deposition of aggregated beta -amyloid protein in the microglial activation to these unwanted outcomes.

T2DM is thought to arise in its earliest stage from decreased sensitivity of peripheral tissues to circulating insulin, leading to impaired glucose tolerance, compensatory hyperinsulinemia in an of cellular insulin resistance and insulin insufficiency is occurring in the brain in AD is becoming evident, including in those without systemic diabetes, and for this reason some have referred to AD as “ type 3 diabetes.

Recent advances in the understanding of the biology of T2DM have resulted in a growing number of therapies that are approved or in clinical development for this disease. During the talk, beyond review the possible mechanisms between T2DM and AD, I am going to assesses the various diabetes drugs for their potential activity in AD to determine their value for AD in general.

SD5-1

CURRENT STATUS OF DIABETIC FOOT CARE IN TAIWAN AND TREATMENT OF INFECTION

1% 3.2‰ 6.14 3.25 80% 2016 5 30 IWGDF 2015 guidance Society for Vascular Surgery Podiatric Medical Association Society for Vascular Medicine 2016 practice guideline American Heart Association American College of Cardiology 2016 Lower Extremity PAD guideline 2016

SD5-2

PERIPHERAL ARTERY DISEASE MANAGEMENT IN PATIENTS WITH DIABETIC FOOT ULCER

WEI-KUNG MD, PHD

Division of Cardiology, Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan, Department of Medical Imaging and Radiological Sciences, I-Shou University, Kaohsiung, Taiwan

Diabetes is strongly associated with the presence of peripheral artery disease (PAD). PAD is not only an independent risk factor for developing foot ulceration and amputation, it is also associated with a higher risk of cardiovascular disease and overall mortality. Therefore it is important to diagnose PAD promptly and accurately, and to take steps to minimize its deleterious effects.

The diagnosis of PAD is challenging in patients with diabetes. Medical history and physical may mask symptom of PAD. Co-exist arteriosclerosis, edema and infection make clinical assessment minimum, taking a history and palpating foot pulses. For patients with diabetes and foot ulcer, further non-invasive tests should be arranged for determine the presence of PAD. the detection ofPAD across a spectrum of patients with diabetes. Non-invasive tests for the detection of PAD among individualswith diabetes are important to estimate the risk of amputation, ulceration, wound healing and presence of cardiovascular disease.Ankle brachial index (ABI) is the most widely used for screening of PAD, with exclusion of PAD at value 0.9 - 1.3. Alternative toe brachial index (TBI) <0.75 and Doppler wave form analysis could be other screening tests for PAD. predict healing of the ulcer. Diabetic microangiopathy should not be assumed to be the cause of poor wound healing in patients with a foot ulcer. Consider urgent vascular imaging and revascularization in a patient with toe pressure <30 mmHg, ankle pressure <50 mmHg, ABI < 0.5 and ulcer does not improve within 6 weeks despite optimal management.

Vascular image include color duplex ultrasound, computed tomography angiography, magnetic resonance angiography or intraarterial digital subtraction angiography to obtain anatomical information when revascularization is being considered. Revascularization can be performed either by endovascular techniques or surgical bypass. There is inadequate evidence to establish which revascularization technique is superior, and decisions should be made

arteries, preferably the artery that supplies the anatomical region (angiosome) of the wound. After

revascularization procedure, patient should be treated by multi-disciplinary and comprehensive program. Patients with signs of PAD and a foot infection (critical limb ischemia, CLI) are at particularly high risk for major limb amputation and require urgent treatment. All patients with diabetes and an ischemic foot ulcer should receive aggressive cardiovascular risk management, including risk factors control, antiplatelet and statin.

SD5-3

DIABETIC FOOT WOUND HEALING AND SURGICAL TREATMENT

CHERNG-KANG PERNG M.D., PH.D.

Division of Plastic and Reconstruction Surgery, Department of Surgery, Taipei Veterans General Hospital

The treatment of diabetic foot ulcers is still a major challenge in clinical practice. There is still a lot of uncertainty about the choice of best treatment. Since 2008, the International Diabetes Foot Working Group (IWGDF) has conducted a number of systematic review on the topic of wound healing, for clarifying the evidence of the routine care program efficacy, and further analyzing the effect of interventional treatment for improving chronic ulcer healing reported in literature.

At present, the interventional treatment of chronic ulcer can be divided into the following ten categories: sharp debridement and wound bed preparation with larvae or hydrotherapy; wound bed preparation using antiseptics, applications and dressing products; resection of the chronic wound; oxygen and other gases, compression or negative pressure therapy; products designed to correct aspects of wound biochemistry and cell biology associated with impaired wound healing; application of cells, including platelets and stem cells; bioengineered skin and skin grafts; electrical, the above categories.

Despite there are currently considerable number of treatment methods for diabetic foot and chronic ulcers, and new methods also been developed, the effectiveness of diabetic foot treatment is still a challenge. The cost and benefit of new treatments must be thoroughly studied and analyzed. From the evidence of the current literature, most of the current treatment for chronic wounds are lack of strong evidence support. We will review the current approach to the treatment of diabetic foot and chronic ulcer in Taiwan, and put forward our recommendations and guidelines.

SD5-4

OFFLOADING AND PREVENTION OF DIABETIC FOOT ULCER

1,2 C-K CHEN

1Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Taoyuan, Taiwan, R.O.C. 2College of Medicine, Chang Gung University, Taiwan, R.O.C.

To prevent diabetic foot ulcer, a wide variety of interventions have been used in clinical practice. the at-risk foot by annual screening for signs and symptoms of peripheral neuropathy and peripheral artery disease; (2) regular inspection and examination of the feet and footwear/socks, especially in high-risk diabetics patients; (3) education of patient, family and healthcare providers about preventive foot care in an organized, structured and repeated manner; (4) routine wearing of properly fitting footwear to prevent a first foot ulcer, either plantar or non-plantar, or a recurrent non-plantar foot ulcer, both indoors and outdoors; and (5) treatment of any pre-ulcerative sign on the foot until the preulcerative sign resolves and not recur over time.

In addition, offloading plays an important role in preventing and healing diabetic foot ulcers. The commonly used offloading techniques consist of casting and prefabricated healing devices,