Guía de práctica clínica para el diagnóstico y tratamiento de la enfermedad del pie relacionada con diabetes (actualización 2025)
Barra lateral del artículo
Contenido principal del artículo
Resumen
Introducción: La enfermedad del pie relacionada con diabetes es una condición de alta morbilidad para los pacientes con diabetes y relevancia para los sistemas de salud. Su enfoque debe ser integral y dirigido al control y manejo de sus diversas manifestaciones. Desde la publicación de la primera versión de la Guía de Práctica Clínica en el año 2019 ha surgido nueva evidencia sobre tecnologías diagnósticas y terapéuticas para el manejo de esta condición. Materiales y métodos: La presente actualización fue realizada por la alianza de 11 sociedades científicas colombianas y la Universidad Nacional de Colombia. Los procesos de priorización, búsqueda, síntesis, evaluación de la certeza de la evidencia y formulación de recomendaciones se hizo siguiendo la metodología GRADE. Los detalles de la metodología se encuentran disponibles en la versión completa de la guía. Resultados: Se actualizaron recomendaciones para el diagnóstico, la clasificación de la severidad y pronóstico de la enfermedad, el tratamiento farmacológico y no farmacológico de pacientes con diabetes y la presencia de úlcera, infección, enfermedad arterial periférica o neuropatía del pie. Discusión: El manejo de los pacientes con enfermedad del pie relacionada con diabetes requiere de un abordaje integral, con un diagnóstico oportuno, una clasificación de la severidad adecuada y un tratamiento farmacológico y no farmacológico oportuno orientado al manejo de las diversas manifestaciones de esta enfermedad.
Detalles del artículo
Citas
Organización Panamericana de la Salud. Diabetes Washington D.C.: Organización Panamericana de la Salud; 2025 [cited 2025]. Available from: https://www.paho.org/es/temas/diabetes#:~:text=Datos%2FEstad%C3%ADsticas-,112%20millones%20de%20adultos%20(de%2018%20a%C3%B1os%20o%20m%C3%A1s),%25%20de%20la%20poblaci%C3%B3n%20adulta).
International Working Group on the Diabetic Foot. IWGDF Guidelines on the prevention and management of diabetes-related foot disease. The Netherlands: International Working Group on the Diabetic Foot; 2023. Available from: https://iwgdfguidelines.org/.
van Netten JJ, Bus SA, Apelqvist J, Lipsky BA, Hinchliffe RJ, Game F, et al. Definitions and criteria for diabetic foot disease. Diabetes Metab Res Rev. 2020;36 Suppl 1:e3268. Epub 20200114. PubMed PMID: 31943705. https://doi.org/10.1002/dmrr.3268
National Institute for Health and Care Excellence. Diabetic foot problems: prevention and management. (Full guideline). London, England: National Institute for Health and Care Excellence, 2019.
Organización Panamericana de la S, Organización Panamericana de la S. Directriz para el fortalecimiento de los programas nacionales de guías informadas por la evidencia. Una herramienta para la adaptación e implementación de guías en las Américas. 2018. https://doi.org/10.37774/9789275320167
Ministerio de la Protección Social, Colciencias, Grupo de actualización de la Guía Metodológica para el desarrollo de Guías de Práctica Clínica con Evaluación Económica en el Sistema General de Seguridad Social en Salud Colombiano. Guía Metodológica para la elaboración de Guías de Práctica Clínica con Evaluación Económica en el Sistema General de Seguridad Social en Salud Colombiano. 2014. Available from: http://gpc.minsalud.gov.co/recursos/Documents/Gu%C3%ADa%20Metodol%C3%B3gica_Web.pd
Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017;358:j4008. Epub 2017/09/25. PubMed PMID: 28935701; PubMed Central PMCID: PMC5833365 at http://www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work. https://doi.org/10.1136/bmj.j4008
Whiting PF, Smidt N, Sterne JA, Harbord R, Burton A, Burke M, et al. Systematic review: accuracy of anti-citrullinated Peptide antibodies for diagnosing rheumatoid arthritis. Ann Intern Med. 2010;152(7):456-64. W155-66. Epub 2010/04/07. PubMed PMID: 20368651. https://doi.org/10.7326/0003-4819-152-7-201004060-00010
Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al. Cochrane Handbook for Systematic Reviews of Interventions. London: Cochrane; 2024. Available from: www.training.cochrane.org/handbook.
Brozek JL, Akl EA, Alonso-Coello P, Lang D, Jaeschke R, Williams JW, et al. Grading quality of evidence and strength of recommendations in clinical practice guidelines. Part 1 of 3. An overview of the GRADE approach and grading quality of evidence about interventions. Allergy. 2009;64(5):66977. Epub 2009/02/13. PubMed PMID: 19210357. https://doi.org/10.1111/j.1398-9995.2009.01973.x
Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924-6. Epub 2008/04/26. PubMed PMID: 18436948; PubMed Central PMCID: PMC2335261. https://doi.org/10.1136/bmj.39489.470347.AD
Schunemann H, Brozek J, Guyatt G, Oxman A. GRADE handbook for grading quality of evidence and strength of recommendations. Canada: The GRADE Working Group; 2013. Available from: guidelinedevelopment.org/handbook.
Ansert EA, Tarricone AN, Coye TL, Crisologo PA, Truong D, Suludere MA, et al. Update of biomarkers to diagnose diabetic foot osteomyelitis: A meta-analysis and systematic review. Wound Repair and Regeneration. 2024;32(4):366-76. https://doi.org/10.1111/wrr.13174
Calvo-Wright MDM, Alvaro-Afonso FJ, Lopez-Moral M, Garcia-Alvarez Y, Garcia-Morales E, Lazaro-Martínez JL. Is the Combination of Plain X-ray and Probe-to-Bone Test Useful for Diagnosing Diabetic Foot Osteomyelitis? A Systematic Review and Meta-Analysis. Journal of Clinical Medicine. 2023;12(16). https://doi.org/10.3390/jcm12165369
Trihan JE, Mahe G, Croquette M, Coutant V, Thollot C, Guillaumat J, et al. Accuracy of Acceleration Time of Distal Arteries to Diagnose Severe Peripheral Arterial Disease. Front Cardiovasc Med. 2021;8:744354. Epub 2022/02/08. PubMed PMID: 35127845; PubMed Central PMCID: PMC8810631. https://doi.org/10.3389/fcvm.2021.744354
Senneville E, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragon- Sanchez J, et al. IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023). Clin Infect Dis. 2023. Epub 2023/10/02. PubMed PMID: 37779457. https://doi.org/10.1093/cid/ciad527
The International Working Group on the Diabetic Foot. 2019 IWGDF Guidelines on the Prevention and Management of Diabetic Foot Disease. Foot TIWGotD, editor. United States: The International Working Group on the Diabetic Foot; 2019. 194 p.
Huang J, Yang J, Qi H, Xu M, Xu X, Zhu Y. Prediction models for amputation after diabetic foot: systematic review and critical appraisal. Diabetol Metab Syndr. 2024;16(1):126. Epub 20240610. PubMed PMID: 38858732; PubMed Central PMCID: PMC11163763. https://doi.org/10.1186/s13098-024-01360-6
Martinez-De Jesus FR, Hernandez-Luevano E, Rodriguez-Ramirez N, Cendejas-Alatorre R, Munoa Prado JA, Carrera Maigua F, et al. Validation of the Ischaemia Severity Scale (ISS) Based on Non-Invasive Vascular Assessments (SEWSS) for Predicting Outcomes of Diabetic Foot Attack. J Clin Med. 2022;11(23). Epub 20221203. PubMed PMID: 36498772; PubMed Central PMCID: PMC9738640. https://doi.org/10.3390/jcm11237195
Carro GV, Saurral R, Carlucci E, Gette F, Llanos M, Amato PS. A Comparison Between Diabetic Foot Classifications WIfI, Saint Elian, and Texas: Description of Wounds and Clinical Outcomes. Int J Low Extrem Wounds. 2022;21(2):120-30. Epub 20200628. PubMed PMID: 32594809. https://doi.org/10.1177/1534734620930171
Oley MH, Oley MC, Kepel BJ, Faruk M, Wagiu AMJ, Sukarno I, et al. Hyperbaric Oxygen Therapy for Diabetic Foot Ulcers Based on Wagner Grading: A Systematic Review and Meta-analysis. Plast Reconstr Surg Glob Open. 2024;12(3):e5692. Epub 20240325. PubMed PMID: 38528847; PubMed Central PMCID: PMC10962882. https://doi.org/10.1097/GOX.0000000000005692
Moreira DACDL, Oliveira-Pinto J, Mansilha A. The role of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers: a systematic review with meta-analysis of randomized controlled trials on limb amputation and ulcer healing. Int Angiol. 2022;41(1):63-73. Epub 20210708. PubMed PMID: 34236155. https://doi.org/10.23736/S0392-9590.21.04722-2
Thanigaimani S, Singh T, Golledge J. Topical oxygen therapy for diabetesrelated foot ulcers: A systematic review and meta-analysis. Diabet Med. 2021;38(8):e14585. Epub 20210429. PubMed PMID: 33871095. https://doi.org/10.1111/dme.14585
Barrigah-Benissan K, Ory J, Sotto A, Salipante F, Lavigne JP, Loubet P. Antiseptic Agents for Chronic Wounds: A Systematic Review. Antibiotics (Basel). 2022;11(3). Epub 20220306. PubMed PMID: 35326813; PubMed Central PMCID: PMC8944418. https://doi.org/10.3390/antibiotics11030350
Bellingeri A, Falciani F, Traspedini P, Moscatelli A, Russo A, Tino G, et al. Effect of a wound cleansing solution on wound bed preparation and inflammation in chronic wounds: a single-blind RCT. J Wound Care. 2016;25(3):160, 2-6, 8. Epub 2016/03/08. PubMed PMID: 26947697. https://doi.org/10.12968/jowc.2016.25.3.160
Sibbald RG, Coutts P, Woo KY. Reduction of bacterial burden and pain in chronic wounds using a new polyhexamethylene biguanide antimicrobial foam dressing-clinical trial results. Adv Skin Wound Care. 2011;24(2):7884. Epub 2011/01/19. PubMed PMID: 21242737. https://doi.org/10.1097/01.ASW.0000394027.82702.16
Woo K, Dowsett C, Costa B, Ebohon S, Woodmansey EJ, Malone M. Efficacy of topical cadexomer iodine treatment in chronic wounds: Systematic review and meta-analysis of comparative clinical trials. Int Wound J. 2021;18(5):586-97. Epub 20210208. PubMed PMID: 33559332; PubMed Central PMCID: PMC8450789. https://doi.org/10.1111/iwj.13560
Hu XX, Xiu ZZ, Li GC, Zhang JY, Shu LJ, Chen Z, et al. Effectiveness of transverse tibial bone transport in treatment of diabetic foot ulcer: A systematic review and meta-analysis. Front Endocrinol (Lausanne). 2022;13:1095361. Epub 20230104. PubMed PMID: 36686461; PubMed Central PMCID: PMC9846025. https://doi.org/10.3389/fendo.2022.1095361
Monami M, Ragghianti B, Scatena A, Miranda C, Monge L, Uccioli L, et al. Effectiveness of different advanced wound dressings versus standard of care for the management of diabetic foot ulcers: a meta-analysis of randomized controlled trials for the development of the Italian guidelines for the treatment of diabetic foot syndrome. Acta Diabetol. 2024;61(12):1517-26. Epub 20240612. PubMed PMID: 38864979. https://doi.org/10.1007/s00592-024-02320-2
Brouwer RJ, Lalieu RC, Hoencamp R, van Hulst RA, Ubbink DT. A systematic review and meta-analysis of hyperbaric oxygen therapy for diabetic foot ulcers with arterial insufficiency. J Vasc Surg. 2020;71(2):682-92 e1. PubMed PMID: 32040434. https://doi.org/10.1016/j.jvs.2019.07.082
Chen HR, Lu SJ, Wang Q, Li ML, Chen XC, Pan BY. Application of hyperbaric oxygen therapy in diabetic foot ulcers: A meta-analysis. Int Wound J. 2024;21(4):e14621. PubMed PMID: 38531355; PubMed Central PMCID: PMC10965274. https://doi.org/10.1111/iwj.14621
Sharma R, Sharma SK, Mudgal SK, Jelly P, Thakur K. Efficacy of hyperbaric oxygen therapy for diabetic foot ulcer, a systematic review and metaanalysis of controlled clinical trials. Sci Rep. 2021;11(1):2189. Epub 20210126. PubMed PMID: 33500533; PubMed Central PMCID: PMC7838311. https://doi.org/10.1038/s41598-021-81886-1
Carter MJ, Frykberg RG, Oropallo A, Sen CK, Armstrong DG, Nair HKR, et al. Efficacy of Topical Wound Oxygen Therapy in Healing Chronic Diabetic Foot Ulcers: Systematic Review and Meta-Analysis. Adv Wound Care (New Rochelle). 2023;12(4):177-86. Epub 20220621. PubMed PMID: 35593010; PubMed Central PMCID: PMC9885545. https://doi.org/10.1089/wound.2022.0041
Sun XK, Li R, Yang XL, Yuan L. Efficacy and safety of topical oxygen therapy for diabetic foot ulcers: An updated systematic review and meta-analysis. Int Wound J. 2022;19(8):2200-9. Epub 20220505. PubMed PMID: 35510518; PubMed Central PMCID: PMC9705166. https://doi.org/10.1111/iwj.13830
Gordon AJ, Alfonso AR, Nicholson J, Chiu ES. Evidence for Healing Diabetic Foot Ulcers With Biologic Skin Substitutes: A Systematic Review and Meta-Analysis. Ann Plast Surg. 2019;83(4S Suppl 1):S31-S44. PubMed PMID: 31513064. https://doi.org/10.1097/SAP.0000000000002096
Zhao H, Wu Y, Xie Y, Li Y, Chen C, Li C, et al. Hydrogel dressings for diabetic foot ulcer: A systematic review and meta-analysis. Diabetes Obes Metab. 2024;26(6):2305-17. Epub 20240311. PubMed PMID: 38465784. https://doi.org/10.1111/dom.15544
Meneses J, Borges JWP, Silva A, Viana MCA, Reboucas VCF, Alencar A. The effects of felted foam in diabetic foot treatment: systematic review with meta-analysis. Rev Esc Enferm USP. 2020;54:e03640. Epub 20201211. PubMed PMID: 33331499. https://doi.org/10.1590/s1980-220x2019026903640
Deng J, Yang M, Zhang X, Zhang H. Efficacy and safety of autologous platelet-rich plasma for diabetic foot ulcer healing: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res. 2023;18(1):370. Epub 20230519. PubMed PMID: 37202812; PubMed Central PMCID: PMC10197861. https://doi.org/10.1186/s13018-023-03854-x
Mohammed YA, Farouk HK, Gbreel MI, Ali AM, Salah AA, Nourelden AZ, et al. Human amniotic membrane products for patients with diabetic foot ulcers. do they help? a systematic review and meta-analysis. J Foot Ankle Res. 2022;15(1):71. Epub 20220914. PubMed PMID: 36104736; PubMed Central PMCID: PMC9472416. https://doi.org/10.1186/s13047-022-00575-y
Guo J, Dardik A, Fang K, Huang R, Gu Y. Meta-analysis on the treatment of diabetic foot ulcers with autologous stem cells. Stem Cell Res Ther. 2017;8(1):228. Epub 20171016. PubMed PMID: 29037219; PubMed Central PMCID: PMC5644171. https://doi.org/10.1186/s13287-017-0683-2
Babak P, Hossein P, Massih Sedigh R, Elham H, Mohadeseh O, Azizallah D, et al. A Complementary Therapy with Whey Protein in Diabetes: A Double-Blind Randomized Controlled Clinical Trial. Traditional and Integrative Medicine. 2023;8(2). https://doi.org/10.18502/tim.v8i2.13081
Arribas-Lopez E, Zand N, Ojo O, Snowden MJ, Kochhar T. The Effect of Amino Acids on Wound Healing: A Systematic Review and Meta-Analysis on Arginine and Glutamine. Nutrients. 2021;13(8). Epub 20210722. PubMed PMID: 34444657; PubMed Central PMCID: PMC8399682. https://doi.org/10.3390/nu13082498
Karedath J, Batool S, Arshad A, Khalique S, Raja S, Lal B, et al. The Impact of Vitamin B12 Supplementation on Clinical Outcomes in Patients With Diabetic Neuropathy: A Meta-Analysis of Randomized Controlled Trials. Cureus. 2022;14(11):e31783. Epub 20221122. PubMed PMID: 36457818; PubMed Central PMCID: PMC9704859. https://doi.org/10.7759/cureus.31783
Wright A, Wood S, De Silva J, Bell JS. Systemic Antimicrobial Therapy for Diabetic Foot Infections: An Overview of Systematic Reviews. Antibiotics (Basel). 2023;12(6). Epub 2023/06/28. PubMed PMID: 37370360; PubMed Central PMCID: PMC10295044. https://doi.org/10.3390/antibiotics12061041
National Institute for Health and Care Excellence. Diabetic foot problems: prevention and management. Evidence Review for diabetic foot infection: antimicrobial prescribing. London, England: National Institute for Health and Care Excellence, 2019.
Peters EJG, Lipsky BA, Senneville E, Abbas ZG, Aragon-Sanchez J, Diggle M, et al. Interventions in the management of infection in the foot in diabetes: a systematic review. Diabetes Metab Res Rev. 2020;36 Suppl 1:e3282. Epub 2020/03/17. PubMed PMID: 32176437. https://doi.org/10.1002/dmrr.3282
Patil SV, Mane RR. Comparison of efficacy of levofloxacin-metronidazole combination versus ceftriaxone in cases of moderate diabetic foot infection. International Journal of Basic & Clinical Pharmacology. 2017;5(5):1775-9. https://doi.org/10.18203/2319-2003.ijbcp20163145
Lipsky BA, Stoutenburgh U. Daptomycin for treating infected diabetic foot ulcers: evidence from a randomized, controlled trial comparing daptomycin with vancomycin or semi-synthetic penicillins for complicated skin and skin-structure infections. J Antimicrob Chemother. 2005;55(2):240-5. Epub 2005/01/22. PubMed PMID: 15659542. https://doi.org/10.1093/jac/dkh531
Dong T, Huang Q, Sun Z. Antibiotic-laden bone cement for diabetic foot infected wounds: A systematic review and meta-analysis. Front Endocrinol (Lausanne). 2023;14:1134318. Epub 20230316. PubMed PMID: 37008902; PubMed Central PMCID: PMC10060955. https://doi.org/10.3389/fendo.2023.1134318
Chen H, Yao L, Zhou Y, Dai J. Evaluation of Antibiotic-Loaded Bone Cement in Treatment of Infected Diabetic Foot: Systematic Review and MetaAnalysis. Diabetes Metab Res Rev. 2024;40(8):e70002. Epub 2024/11/05. PubMed PMID: 39497440. https://doi.org/10.1002/dmrr.70002
Laferriere C, Moazzami C, Belley-Cote E, Bainey KR, Marquis-Gravel G, Fama A, et al. Aspirin for the Primary Prevention of Vascular Ischemic Events: An Updated Systematic Review and Meta-analysis to Support Shared Decision-Making. CJC Open. 2023;5(12):881-90. Epub 2024/01/11. PubMed PMID: 38204851; PubMed Central PMCID: PMC10774080. https://doi.org/10.1016/j.cjco.2023.08.011
Eikelboom JW, Connolly SJ, Bosch J, Dagenais GR, Hart RG, Shestakovska O, et al. Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease. N Engl J Med. 2017;377(14):1319-30. Epub 2017/08/29. PubMed PMID: 28844192. https://doi.org/10.1056/NEJMoa1709118
Su N, Xu T, Li X, Zheng H, Wu B, Zhang S, et al. Heparin and Related Substances for Treating Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne). 2022;13:749368. Epub 20220224. PubMed PMID: 35282468; PubMed Central PMCID: PMC8907383. https://doi.org/10.3389/fendo.2022.749368
Yang Q, Zhang Y, Yin H, Lu Y. Topical Recombinant Human Epidermal Growth Factor for Diabetic Foot Ulcers: A Meta-Analysis of Randomized Controlled Clinical Trials. Ann Vasc Surg. 2020;62:442-51. Epub 20190805. PubMed PMID: 31394225. https://doi.org/10.1016/j.avsg.2019.05.041
Zhao DY, Su YN, Li YH, Yu TQ, Li J, Tu CQ. Efficacy and safety of recombinant human epidermal growth factor for diabetic foot ulcers: A systematic review and meta-analysis of randomised controlled trials. Int Wound J. 2020;17(4):1062-73. Epub 20200428. PubMed PMID: 32343054; PubMed Central PMCID: PMC7948637. https://doi.org/10.1111/iwj.13377
Bui TQ, Bui QVP, Nemeth D, Hegyi P, Szakacs Z, Rumbus Z, et al. Epidermal Growth Factor is Effective in the Treatment of Diabetic Foot Ulcers: Meta-Analysis and Systematic Review. Int J Environ Res Public Health. 2019;16(14). Epub 20190719. PubMed PMID: 31331038; PubMed Central PMCID: PMC6678975. https://doi.org/10.3390/ijerph16142584
Jingxuan L, Litian M, Jianfang F. Different Drugs for the Treatment of Painful Diabetic Peripheral Neuropathy: A Meta-Analysis. Front Neurol. 2021;12:682244. Epub 20211029. PubMed PMID: 34777192; PubMed Central PMCID: PMC8585758. https://doi.org/10.3389/fneur.2021.682244
Liao X, Li SH, El Akkawi MM, Fu XB, Liu HW, Huang YS. Surgical amputation for patients with diabetic foot ulcers: A Chinese expert panel consensus treatment guide. Front Surg. 2022;9:1003339. Epub 20221108. PubMed PMID: 36425891; PubMed Central PMCID: PMC9679004. https://doi.org/10.3389/fsurg.2022.1003339
Li M. Guidelines and standards for comprehensive clinical diagnosis and interventional treatment for diabetic foot in China (Issue 7.0). J Interv Med. 2021;4(3):117-29. Epub 20210816. PubMed PMID: 34805959; PubMed Central PMCID: PMC8562298. https://doi.org/10.1016/j.jimed.2021.07.003