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■ РЕКОНСТРУКТИВНАЯ И МИКРОСОСУДИСТАЯ ХИРУРГИЯ
ИНЪЕКЦИИ ЭПИДЕРМАЛЬНОГО ФАКТОРА РОСТА (НЕВЕКРМТ Р) В ЛОЖЕ И ПО КРАЯМ РАН, ОБУСЛОВЛЕНЫХ СИНДРОМОМ ДИАБЕТИЧЕСКОЙ СТОПЫ
Монтеуин Хосе Фернандез1, Боначеа Ллипсы Сантиестебан2, Асоста Хорге Берланга3, Перез Салихто Валдес1, Гутиеррез Виллиам Савигне1, Дуарте Нестор Алварез1
1 Национальный институт ангиологии и сосудистой хирургии, Гавана, Куба
2 Медицинский университет Гаваны, Куба
3 Биотехнологический и инженерный центр, Гавана, Куба
Ключевые слова:
инъекции эпидермального фактора роста, Heberprot P, диабетическая стопа, язвы
В течение 15 лет, с 2001 г., мы применяем инъекционный метод введения эпидермального фактора роста (Heberprot P, 0,75 мкг), разработанный для лечения рубцов в Центре биотехнологий (Гавана, Куба). Действительно, 159 000 пациентов в более чем 25 странах получили соответствующее лечение, при котором частота высокой ампутации нижних конечностей составила всего 9-11%. В настоящей статье описан опыт авторов по лечению самых тяжелых язв, вызванных синдромом диабетической стопы, за последние 15 лет. Клин. и эксперимент. хир. Журн. им. акад. Б.В. Петровского. 2017. № 4. С. 70-74. Статья поступила в редакцию: 20.08.2017. Принята в печать: 10.10.2017.
Intralesional and perilesional infiltration of an epidermal growth factor (Heberprot P) in diabetic
foot ulcers
Montequin Jose Fernandez1, Bonachea Llipsy Santiesteban2, Acosta Jorge Berlanga3, Perez Calixto
Valdes1, Gutierrez William Savigne1, Duarte Hector Alvarez1
1 National Institute of Angiology and Vascular Surgery, Havana, Cuba
2 Medical University of Havana, Cuba
3 Biotechnologic and Engeneering Center, Havana, Cuba
During 15 years, from 2001, we began to applied Heberprot P, an injectable application of Epidermal Growth Factor (0.75 mcgm) created for the group of cicatrization in the Center of Biotechnol-
Keywords:
injectable application ogy, in Havana Cuba. Actually, more than 25 countries, with 159,000 treated patients around the
of Epidermal Growth Factor, world, were attended with only 9-11% of high level amputations of the inferior extremities. In
Heberprot P, diabetic this paper we introduce experiences of the most principal experiences of members of our team in
foot, ulcers the treatment of the most complicated diabetic foot ulcers, during the last 15 years.
Clin. Experiment. Surg. Petrovsky J. 2017; 5 (4): 70-4.
Received: 20.08.2017. Accepted: 10.10.2017.
Introduction
Diabetic foot ulcers (DFU) are a significant health care problem affecting around 15% of the people with diabetes mellitus in their lifetime [1]. The annual incidence of DFU is more than 2% in all diabetic patients and largely rises when peripheral neuropathy
is present [2]. This condition is an important economic burden to medical care systems demanding 7-20% of the total expenditures on diabetes.
Basic treatment for good wound care in DFU includes strict metabolic control, debridement, offloading (i.e. relieving pressure from the wound area), dress-
Монтеуин Хосе Фернандез, Боначеа Ллипсы Сантиестебан, Асоста Хорге Берланга, Перез Салихто Валдес, Гутиеррез Виллиам Савигне, Дуарте Нестор Алварез ■ ИНЪЕКЦИИ ЭПИДЕРМАЛЬНОГО ФАКТОРА РОСТА (HEBERPROT P) В ЛОЖЕ И ПО КРАЯМ РАН, ОБУСЛОВЛЕНЫХ СИНДРОМОМ ДИАБЕТИЧЕСКОЙ СТОПЫ
I
ings and antimicrobials. New therapies are emerging for low-grade, neuropathic ulcers such as recombinant human platelet-derived growth factor [3-4] and artificial skin substitutes. For high-grade ulcers, which are more likely to progress to amputation, advances in therapy have been scarce [5].
Epidermal growth factor (EGF) plays an important role in the regulation of cell growth, proliferation and differentiation that can be useful to enhance wound healing. Evidences of the beneficial effect of topical EGF application in low-grade, neuropathic ulcers have been shown in clinical trials. However, the effect of topical EGF formulation can be abated, especially in high-grade wounds since an increased protease activity has been identified.
Direct intralesional administration of an EGF-based formulation (Heberprot-P) can overcome this limitation, as has been reported in previous studies and recently confirmed in a randomised, double-blinded, placebo controlled phase III trial in DFU.
In these initial studies, however, Heberprot-P intralesional treatment was continued until a complete granulation response or up to a maximum of 8 weeks. Thus, the safety profile of this intervention modality under a more prolonged application schedule had not be [6].
Methods
In this paper we introduce to you in the principal results we had during our experience using Heberprot P in the treatment of diabetic foot ulcers, during the last 10 years (Fig. 1-4).
A pilot study was performed [7] in 20 patients older than 18 years with diabetes mellitus and fullthickness lower extremity ulcer with more than 4 weeks of evolution. Informed consent to participate in the study was given by the patients. Exclusion criteria were foot ulcer area 1 cm2, cardiopathy (recent acute myocardial infarction, unstable angina or uncontrolled heart failure), renal failure (serum creatinine. 200 mmol/l and oligoanuria), malignancies, pregnancy
Diabetic foot
Fig. 1. Practical procedure
' Metaboliccontrol
' Identification of the diabeticfoot type ' Assessment of the presence and grade of infection Evaluation of the woundsize
/ \ ч
Neuropathic Primary Ischemic
foot amputation foot
and nursing. The exclusion criteria were evaluated during an initial period (2 weeks) when patients received only the standardised good.
Wound care and no more than a 30% decrease in the ulcer size was required. Any sign or symptom of infection should be solved before inclusion as well. This study was approved by institutional review committee.
Patients were treated with intralesional injections of a lyophilized formulation of Heberprot-P containing 75 mg (1 vial) of EGF, three times a week on alternate days up to complete wound healing. Recombinant, human EGF was obtained from a transformed Saccharomyces cerevisiae strain at the Center for Genetic Engineering and Biotechnology of Havana and contained a mixture of the EGF1-51 and EGF1-52 forms. The dose selectionwas based on a better risk-benefit balanceobserved with 75 mg in the accumulated clinical data with this product.
Heberprot-P was administered together with a standardized good wound care regimen.
Ulcers were cleansed daily using saline or chlorhexidine in case of contamination or infection. Sharp debridement was indicated whenever necessary to remove necrotic tissue. Saline-moistened gauze dressing was used and the affected area was pressure off-loaded. Broad-spectrum antibiotics were used to treat infections, whereas metabolic control was
Fig. 2. Protocol for neuropathic foot
Fig. 3. Protocol for primary amputation
Primary amputation
\
Closed
Open
/ \
Complicated • Debridement
Rehabilitation
HEBERPROT-P
HEBERPROT-P
Ischemic foot
Fig. 4. Protocol for ischemic foot
Evaluation of the Revascularization Surgery
\
Revascularization
1 Endovascular techniques • By-Pass
1 Thromboendarterectomy — Surgical regeneration 1 Sympatectomy Others
HEBERPROT-P
No Revascularization
HEBERPROT-P
managed with insulin alone or combined with oral hypoglycemic drugs. Patients were initially hospitalized at 'Hermanos Amejeiras' Hospital up to favorable clinical response (granulation, wound area reduction, no infection or requirement for invasive procedure and adequate metabolic control). The follow up for treatment completion was carried out at the Health Lodging 'Manuel Fajardo', supervised by the same angiologist.
Evaluation consisted of baseline and weekly clinical examinations. Data on demography, personal pathological history, type and duration of diabetes and its current treatment, peripheral neuropathy, peripheral vascular disease and wound examination were documented. Wound area was determined by planimetry using a wound measurement system (Visitrak; Smith & Nephew, Mull, UK). Ankle/
brachial index was taken at baseline. Ulcers were classified in grades according to Wagner-Meggit classification [1]. Laboratory tests were performed at baseline and thereafter whenever required, including blood cell count, haemoglobin, haematocrit,globular sedimentation rate, creatinine and aspartate aminotransferase, which were performed by routine clinical laboratory methods.
Blood glucose was measured more frequently for the patients' metabolic control. Wound cultures were performed before and during therapy if necessary to monitor infections. Foot infection was defined clinically based on the presence of purulent secretions or at least two signs or symptoms of inflammation. The primary efficacy endpoint was complete wound closure defined as skin re-epithelialization without drainage or dressing requirements.
Other variables recorded were complete granulation response, time to complete closure, time to complete granulation response and indication of amputation. Safety was monitored by daily adverse events evaluation during treatment. Data were double entered and validated on Microsoft Visual FoxPro version 5.0 and then imported to SPSS version 13.0 for further analysis. Continuous variables were expressed as mean ± SD. Categorical variables were given as absolute values and percentages. The confidence intervals (CI) for the probabilities of complete granulation and complete wound closure were estimated using a Bayesian logistic model for fixed effects in-WinBUGS14 package. Kaplan-Meier curves for time to complete granulation and complete wound closure were also calculated.
Results
They all suffered type 2 diabetes mellitus. Five patients (25%) received insulin. Mean ulcer size was 16,3+21,3 cm2. In 9 (45%) patients wounds were localized on the sole, 2 of them embracing calcaneus. Other localizations were toes in 8 (40+0%), foot external edge in 2 (10+0%) and internal edge in 1 (5+0%) patients. The principal risk factors were previous history of ulcer in 13 (65+0%) patients, history of amputation in 10 (50+0%) and foot deformity in 10 (50+0%) patients.
Complete treatment compliance was reported in 17 (85%) patients. Voluntary interruption was reported in 3 (15%) cases. Complete granulation response was achieved in all patients, including the three abandoners, at a mean time of 23,6+3,8 days (95% CI: 15,6-31,5). Complete wound closure was obtained in 17 (85%) patients (95% CI: 0,64-0,95). The mean time to complete closure was 4,3+8,9 days (95% CI: 26,9-61,8). Amputation was not necessary in any case and relapse was reported in one patient after 6 months of complete closure (Fig. 5).
Монтеуин Хосе Фернандез, Боначеа Ллипсы Сантиестебан, Асоста Хорге Берланга, Перез Салихто Валдес, Гутиеррез Виллиам Савигне, Дуарте Нестор Алварез ■ ИНЪЕКЦИИ ЭПИДЕРМАЛЬНОГО ФАКТОРА РОСТА (HEBERPROT P) В ЛОЖЕ И ПО КРАЯМ РАН, ОБУСЛОВЛЕНЫХ СИНДРОМОМ ДИАБЕТИЧЕСКОЙ СТОПЫ
In another study we can read about the results in a multicenter, doubled blind placebo control trial, in 149 patients. Below, we highlight the results.
A multicenter double-blind placebo-controlled trial was carried out to evaluate the intra-lesional infiltration of recombinant epidermal growth factor (EGF) in Wagner's grade 3 or 4 diabetic foot ulcers (DFUs). Subjects (149) were randomized to receive EGF (75 or 25 |jg) or placebo, 3 times per week for 8 weeks and standard good wound care. The main endpoint was granulation tissue covering >50% of the ulcer at 2 weeks. It was achieved by 19/48 controls versus 44/53 in the 75 |g group [odds ratio (OR): 7,5; 95% confidence interval (CI): 2,9-18,9] and 34/48 in the
25 |jg group (OR: 3,7; 1,6-8,7). Secondary outcome variables such as end-of-treatment complete granulation response (28/48 controls, 46/53 with 75 |g and 34/48 with 25 |g EGF), time-to-complete response (controls: 5 weeks; both EGF dose groups: 3 weeks), and wound closure after follow-up (25/48 controls, 40/53 with 75 |g and 25/48 with 25 |g EGF) were also treatment dependent. Multivariate analyses yielded that complete granulation response (28/48 controls, 46/53 with 75 |g and 34/48 with 25 |g EGF), time-to-complete response (controls: 5 weeks; both EGF dose groups: 3 weeks), and wound closure after follow-up (25/48 controls, 40/53 with 75 |g and 25/48 with 25 |g EGF) were also treatment dependent. Multivariate
analyses yielded that they were significantly enhanced by 75 |g EGF treatment and neuropathic versus ischemic ulcers. Most adverse events were mild and no drug-related severe adverse reactions were reported. It was concluded that recombinant human EGF (rhEGF) local injections offer a favourable risk-benefit balance in patients with advanced DFU.
Conclusion
In summary, the finding that the EGF intralesional infiltrations enhance the healing of recalcitrant isch-aemic and of complicated and extensive neuropathic diabetic lower extremity lesions offers new hopes for the diabetic wound healing armamentarium. It confirms the role of EGF as potent tissue repair agent under particular delivery circumstances.
References
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2. Abbott C.A., Carrington A.L., Ashe H., Bath S., et al. The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med. 2002; 19: 377-84.
3. Abbott C.A., Vileikyte L., Williamson S., Carrington A.L., et al. Multicenter study of the incidence of and predictive risk factors for diabetic neuropathic foot ulceration. Diabetes Care 1998; 21: 1071-5.
4. Boulton A.J., Vileikyte L., Ragnarson-Tennvall G., Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005; 366: 1719-24.
5. Berlanga J., Lodos J., Reyes O., Infante J.F., et al. Epidermal growth factor stimulated re-epithelialization in pigs. The possible role of acute-wound proteases. Biotecnol Aplicada. 1998; 15: 83-7.
6. Berlanga J., Savigne W., Valdez C., Franco N., et al. Epidermal growth factor intra-lesional infiltrations can preventamputation in diabetic patients with advanced foot ulcers. Int Wound J. 2006; 3: 232-9.
7. Fernandez-Montequin J.I., Infante-Cristia E, Valenzuela-Sil-va C., Franco-Perez N., et al.; Cuban Heberprot-P Study Group. Intra-lesional injections of Citoprot-P® (recombinant human epidermal growth factor) in advanced diabetic foot ulcers with risk of amputation. Int Wound J. 2007; 4: 333-43.
