Diretriz para detecção precoce do pé diabético na atenção primária
Diretriz para detecção precoce do pé diabético na atenção primária
Data
2018
Autores
Casanova, Fabrício
Journal Title
Journal ISSN
Volume Title
Publisher
Instituto Nacional de Cardiologia
Resumo
Introdução: O pé diabético (tríade de neuropatia, arteriopatia e perda da integridade da pele) impacta severamente as pessoas com diabetes. Há escassez de abordagens guiadas com critérios claros de embasamento, utilizando desfechos de interesse e adaptados à realidade brasileira. Objetivos: Elaborar diretriz embasada em evidências, com recomendações para detecção precoce do pé diabético, no contexto da Atenção Primária em Saúde do Sistema Único de Saúde do Brasil. Recomendar também ações de cuidado-padrão. Métodos: Foram realizadas buscas por revisões sistemáticas (e estudos primários, no caso da ausência destas), nas bases Medline/Pubmed, Epistemonikos, Cochrane e Lilacs, incluindo apenas pessoas adultas com diabetes, para os testes: índice tornozelo-braquial (ITB), diapasão, reflexo aquileo, monofilamento (MF), palito, sensibilidade térmica ao metal do diapasão e teste de Ipswich, cujos desfechos foram amputação e morte. Os estudos foram avaliados por instrumentos específicos quanto à qualidade. Finalmente, foi construída diretriz utilizando-se o método GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Resultados: Foram encontradas revisões sistemáticas apenas para o MF e ITB, porém somente para amputação. Para o diapasão e reflexo aquileo, foram encontrados estudos primários, apenas para amputação. Não foram encontrados estudos para os demais dispositivos, nem tampouco estudos de comparação do uso e não uso do dispositivo. A qualidade geral dos estudos variou de baixa a muito baixa. As medidas de associação indicando risco para amputação se teste alterado foram: para o MF, o risco relativo (RR) variou de 1,7 (IC95% 1,1 a 2,6) a 15,1 (IC95% 4,3 a 52,6); para o ITB<0,8 a odds ratio (OR) foi de 2,89 (IC95% 1,65 a 5,05), para o ITB<0,5 o RR foi de 25 (IC95% 13,5 a 41,9); para o reflexo aquileo, RR 4,3 (IC95% 2,5-7,3); para o diapasão, OR 3,46 (IC95% 1,64 a 7,33). Conclusão: Apesar das evidências encontradas serem de baixa qualidade, tendo em vista que o desfecho amputação é de importância crítica e está relacionado à mortalidade; que o uso dos dispositivos diagnósticos é seguro no dia-a-dia, em geral de custo e acessíveis em todo o país; que estimula o aumento dos cuidados com os pés, em geral desejáveis e virtualmente seguras; que respeita valores e preferências de profissionais e usuários, com provável aceitabilidade e viabilidade por estes, a recomendação é elevada para forte em relação ao uso de ITB, MF, reflexo aquileo e diapasão em pessoas com diabetes, com o objetivo de evitar amputações. O cuidado-padrão para manejo das condições relacionadas (tabagismo, hipertensão, dentre outros), inspeção do pé e palpação de pulsos em consulta, como também orientações de autocuidado domiciliar são também fortemente recomendados. Entretanto, estudos primários dos dispositivos, com desfechos de relevância, mostram-se necessários. Um forte candidato a estas novas pesquisas é o teste de Ipswich, que por ser de acurácia comparável ao monofilamento e se diferenciar por não necessitar de dispositivo específico, seria de extrema importância para quaisquer sistemas de saúde, especialmente o SUS.
Background: Diabetic foot (neuropathy, arteriopathy, and loss of skin integrity) impact severely people with diabetes. There is a shortage of guided approaches with clear baseline criteria, using outcomes of interest and adaptations to the Brazilian reality. Objectives: To elaborate an evidence-based guideline, with recommendations for early detection of diabetic foot in the Primary Health Care of the Brazilian Unified Health System. Perform also recommends a standard of care. Methods: Systematic reviews (and primary studies, in case of absence) were searched in the databases Medline / Pubmed, Epistemonikos, Cochrane and Lilacs. Adults with diabetes were included for the testes: ankle-brachial index (ABI), tuning fork, ankle reflex, monofilament (MF), pinprick, thermal sensitivity to tuning fork metal and Ipswich test. The outcomes were amputation and death. The studies were evaluated by specific instruments regarding quality. Finally, a guideline was built using the GRADE method (Grading of Recommendations, Assessment, Development and Evaluation). Results: Systematic reviews were found only for MF and ABI, just for amputation. For aquileo reflex and tuning fork, primary studies were found only for amputation. No studies were found for the other devices, nor did any studies comparing the use and non-use of the device. The overall quality of the studies ranged from low to very low. The association measures indicating risk for amputation if altered test were: for MF, the relative risk (RR) ranged from 1.7 (95% CI 1.1 to 2.6) to 15.1 (95% CI 4.3 to 52.6); for ABI <0.8 the odds ratio (OR) was 2.89 (95% CI 1.65 to 5.05), for ABI <0.5: RR 25 (95% CI 13.5 to 41 , 9); for the ankle reflex: RR 4.3 (95% CI 2.5-7.3); for tuning fork: OR 3.46 (95% CI 1.64 to 7.33). Conclusion: Although the evidence found is of low quality, the use of the diagnostic devices is safe in the day-to-day, generally of cheap cost and accessible throughout the country. It involves desirable and virtually safe consequences of increased foot care; respects values and preferences of professionals and patients. For all this, the recommendation is strong for use ABI, MF, ankle reflex and tuning fork in people with diabetes, to avoid amputations. The standard of care for the management of related conditions (smoking, hypertension, among others), foot inspection and pulse palpation in consultation, as well as self-care guidelines, are also strongly recommended. However, primary studies of the devices, with relevant outcomes, are necessary. A strong candidate for these new researches is the Ipswich test. It has accuracy comparable to monofilament and differentiates itself because it does not require a specific device. It would be extremely important for any health system, especially SUS.
Background: Diabetic foot (neuropathy, arteriopathy, and loss of skin integrity) impact severely people with diabetes. There is a shortage of guided approaches with clear baseline criteria, using outcomes of interest and adaptations to the Brazilian reality. Objectives: To elaborate an evidence-based guideline, with recommendations for early detection of diabetic foot in the Primary Health Care of the Brazilian Unified Health System. Perform also recommends a standard of care. Methods: Systematic reviews (and primary studies, in case of absence) were searched in the databases Medline / Pubmed, Epistemonikos, Cochrane and Lilacs. Adults with diabetes were included for the testes: ankle-brachial index (ABI), tuning fork, ankle reflex, monofilament (MF), pinprick, thermal sensitivity to tuning fork metal and Ipswich test. The outcomes were amputation and death. The studies were evaluated by specific instruments regarding quality. Finally, a guideline was built using the GRADE method (Grading of Recommendations, Assessment, Development and Evaluation). Results: Systematic reviews were found only for MF and ABI, just for amputation. For aquileo reflex and tuning fork, primary studies were found only for amputation. No studies were found for the other devices, nor did any studies comparing the use and non-use of the device. The overall quality of the studies ranged from low to very low. The association measures indicating risk for amputation if altered test were: for MF, the relative risk (RR) ranged from 1.7 (95% CI 1.1 to 2.6) to 15.1 (95% CI 4.3 to 52.6); for ABI <0.8 the odds ratio (OR) was 2.89 (95% CI 1.65 to 5.05), for ABI <0.5: RR 25 (95% CI 13.5 to 41 , 9); for the ankle reflex: RR 4.3 (95% CI 2.5-7.3); for tuning fork: OR 3.46 (95% CI 1.64 to 7.33). Conclusion: Although the evidence found is of low quality, the use of the diagnostic devices is safe in the day-to-day, generally of cheap cost and accessible throughout the country. It involves desirable and virtually safe consequences of increased foot care; respects values and preferences of professionals and patients. For all this, the recommendation is strong for use ABI, MF, ankle reflex and tuning fork in people with diabetes, to avoid amputations. The standard of care for the management of related conditions (smoking, hypertension, among others), foot inspection and pulse palpation in consultation, as well as self-care guidelines, are also strongly recommended. However, primary studies of the devices, with relevant outcomes, are necessary. A strong candidate for these new researches is the Ipswich test. It has accuracy comparable to monofilament and differentiates itself because it does not require a specific device. It would be extremely important for any health system, especially SUS.
Description
Palavras-chave
Mortalidade, Amputação, Doença arterial periférica, Neuropatias diabéticas, Pé diabético, Mortality, Amputation, Peripheral Arterial Disease, Diabetic Neuropathies, Diabetic foot
Citação
Casanova F. Diretriz para detecção precoce do pé diabético na atenção primária. Rio de Janeiro. Dissertação [Mestrado Profissional em Avaliação de Tecnologias em Saúde] - Instituto Nacional de Cardiologia; 2018.