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Diabetes Care 29:951-952, 2006
DOI: 10.2337/diacare.29.04.06.dc06-0010
© 2006 by the American Diabetes Association
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Letters: Comments and Responses

Acute Neuropathic Joint Disease: A Medical Emergency?

Response to Tan et al.

William J. Jeffcoate, MRCP1, Fran L. Game, FRCP1, David G. Armstrong, DPM, PHD2 and Peter R. Cavanagh, PHD3

1 Department of Diabetes and Endocrinology, Nottingham City Hospital, Nottingham, U.K.
2 Rosalind Franklin University of Medicine and Science, Dr. William M. Scholl College of Podiatric Medicine, Chicago, Illinois
3 Diabetic Foot Care Program, Cleveland Clinic, Cleveland, Ohio

Address correspondence to William Jeffcoate, Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, City Hospital, Nottingham, NG5 1PB, UK. E-mail: wjeffcoate{at}futu.co.uk

We read with some interest the commentary by Tan et al. (1) on the management of the Charcot foot in diabetes. While we agree entirely that this condition should be ranked as a medical emergency, because failure to act quickly can lead to irreversible adverse consequences, we do not agree that the evidence is available to support uncritical use of bisphosphonates. The only blinded trials conducted so far did not demonstrate any overt improvement in long-term prognosis (2,3). There is much suggestive evidence to favor the consideration of bisphosphonate use, but it is not currently accepted by all authorities that this therapy is essential.

A number of other treatments also deserve consideration (4,5). For example, intranasal calcitonin and tumor necrosis factor-{alpha} antagonists may prove useful, although the efficacy of both has yet to be established in controlled trials. In the absence of evidence to support the use of specific treatments, it is accepted by all with a specialist interest in this field that the mainstay of emergency management is the immediate institution of effective offloading, preferably in a total contact cast. Offloading results in protection of the bones and joints of the foot, as well as amelioration of the underlying inflammatory process.

References

  1. Tan AL, Greenstein A, Jarrett SJ, McGonagle D: Acute neuropathic joint disease: a medical emergency? Diabetes Care 28:2962–2964, 2005[Free Full Text]
  2. Jude EB, Selby PL, Burgess J, Lillystone P, Mawer B, Page SR, Donohoe M, Foster AV, Edmonds ME, Boulton AJ: Pamidronate in diabetic Charcot arthropathy: a randomised placebo controlled trial. Diabetologia 44:2032–2037, 2001[Medline]
  3. Pitocco D, Ruotolo V, Caputo S, Mancini L, Collina CM, Manto A, Caradonna P, Ghirlanda G: Six-month treatment with alendronate in acute Charcot neuroarthropathy: a randomized controlled trial. Diabetes Care 28:1214–1215, 2005[Free Full Text]
  4. Jeffcoate W: Vascular calcification and osteolysis in diabetic neuropathy-is RANK-L the missing link (Review)? Diabetologia 47:1488–1492, 2004[Medline]
  5. Jeffcoate WJ, Game F, Cavanagh PR: The role of proinflammatory cytokines in the cause of neuropathic osteoarthropathy (acute Charcot foot) in diabetes. Lancet 366:2058–2061, 2005[Medline]

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A. L. Tan and D. McGonagle
Acute Neuropathic Joint Disease: A Medical Emergency?: Response to Jeffcoate et al.
Diabetes Care, April 1, 2006; 29(4): 952 - 952.
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