THE SCOPING REVIEW OF CHINESE AND WESTERN MEDICINE TREATMENT OF DIABETIC FOOT IN ASIA 

Wang Xinyanimage, Wang Yinuo*image, Yu Hanyiimage, Muhammad Shahzad Aslamimage

            School of Traditional Chinese Medicine, Xiamen University Malaysia, Jalan Sunsuria. Bandar Sunsuria, Sepang. Selangor. 43900, Malaysia

ABSTRACT

Diabetic foot is a common and serious chronic complication of diabetes due to the simultaneous occurrence of diabetic peripheral neuropathy and vascular lesion. Among all complications, foot ulcers in diabetic ulcers account for the first place among the reasons for hospitalization and treatment of diabetic patients. 15% of diabetic patients may have foot diseases, and 85% of patients may have foot ulcers as the cause of amputation. Diabetic foot seriously affects the quality of life of patients. Although there are many methods to treat diabetic foot, the therapeutic effect of diabetic foot is not ideal in general. The main purpose of this scoping review was analyzing the existing loopholes of researches on diabetic foot in Asia. Used Pub Med, CNKI, Wangfang data, CQVIP to search and select 5 traditional Chinese medicine literatures and 5 western medicine literature, through the comparison of various conditions between literature to analyze the lack of research. Ten pieces of literature were retained through 183 records and included 9 drugs or decoction, they were adipose-derived stem cell–hydrogel complex, hyperbaric oxygen therapy, Xenogeneic (porcine) a cellular dermal matrix, alprostadil, salvia miltiorrhiza polyphenols for injection and collagen sponge, Taohong Siwu Decoction, Simiao Yong an Decoction, Jiawei Simiao Yong an Decoction, Huangqi Guizhi Wuwu Tang, and Wuwei Xiaodu Drink. The obvious problems found by this scoping review were the quantity and quality deficiency of the research in the diabetic foot in Asia. Scoping review is an effective method of evidence identification and synthesis, which can provide a basis for the further development of a certain field. In the further study of the diabetic foot, more attention should be paid to the verification of experimental data as well as the feasibility of the researches on oral drugs. 

Keywords: Diabetic foot, Traditional Chinese medicine, Western medicine.


INTRODUCTION

Diabetic foot is a general term for a series of clinical manifestations of the foot caused by peripheral vascular disease, neuropathy, and infection in diabetic patients due to long-term and chronically elevated blood glucose, including foot ulcers, infection and deep tissue destruction. Once diabetic foot occurs, it is difficult to treat, with the high cost and poor prognosis. If the treatment is not timely or adequate, there is often a risk of amputation. Diabetic foot is one of the main complications of diabetes. According to the IDF diabetes map (9th edition), about 463 million adults worldwide suffered from diabetes in 2019, and it is estimated that 700 million people could have diabetes by 2045 Figure 1 shows the global distribution of diabetes patients in 20191.  At the national level, the top three countries with diabetes in 2019 were China, India and the United States, with about 118 million, 78 million and 30 million diabetics (20-79 years old), respectively. And China and the United States also have a high expenditure with diabetics 1. Figure 2 shows the top 10 countries with the highest number of diabetes in 2019. Based on the above data, the number of diabetes patients in Asia is the first in the world. In global diabetes research, the study of American forces dominates. Diabetes research in China in the number of papers and patents statistics on has and Germany are close to, or more than these countries, but from the paper quality in new drug research and clinical research level, with Europe and the United States and other developed countries have a certain gap2. Because Asian countries the number of diabetes and the number of concurrent with diabetic foot ulcers are more, but at this stage of clinical research level is not high, the number of new drug research, research direction is fuzzy, therefore decided to Asian drug therapy for diabetic foot ulcers group scoping review, to provide reference for drug treatment for the future research direction. A scoped review is a design approach "to rapidly map the key concepts underpinning the research field as well as the key resources and types of available evidence"3. This scoping review is to summarize the current clinical research literature on Chinese medicine and western medicine for diabetic foot treatment in Asia, so as to provide new ideas for the future research direction of diabetic foot medicine in Asia and facilitate the further development of research.

Table 1: Nine drugs or prescriptions and their effects in treating diabetic foot.


                                                             

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Figure 1: Number of diabetes patients worldwide (20-79 years old) in 2019


METHODS

Eligibility Criteria

Literature including nearly five years (2015-2019) in four databases of free text articles. Literature type limited to the clinical trial. Intervention limited to drugtreatment. Study design limited to randomized controlled trials. The population limit for Asians, any 

gender, most was over 35 years old, and the study population was limited to 30 or more (N > 30).

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Figure 2: Top 10 countries with the highest number of diabetics in 2017 

(the red bar represents health spending)



Search Strategy

The databases used are CNKI (China National Knowledge Infrastructure), PubMed and CQVIP (China Science and Technology Journal Database), Wanfang Data Knowledge Service Platform. In the process of visual search of three databases, the search of the literature will be stopped until the literature in the database does not conform to the content of the literature required by the re problem which is researched. The search strategy is based on the review of the clinical research progress of Chinese and western medicine in treating diabetic foot and the management of diabetic foot ulcers and extends to the differences in the treatment of diabetic foot with Chinese and western medicine4,5. The common terms used in different databases include diabetic foot (including diabetes foot); broad terms such as non-surgical debridement agents; narrower terms such as hydrogels. The literature published after 2015 was searched until all the required literature was retrieved.

Figure 3: Process of identifying, screening, including, and excluding literature.

Study Selection

Three researchers examined the search records of the first layer cooperatively, at the first place screening by the published date, title and abstract, secondly, by full text. When a disagreement arises between the researchers, the controversial papers should first be retained and then screened according to drug type of the papers as well asa comparison of the literature describing the same classification of drugs.


Table 2: The basic information of all the experiments.

Charting the Data

Before the data analysis, two articles were used to discuss the process of data analysis. After collecting the data, three researchers summarized, analyzed and compared, and agreed on the types of data items including drug therapy, study method, inclusion and exclusion criteria of participants (not included in the report) and treatment results.

 

RESULTS

The purpose of this scoping review is to summarize the existing studies on drug therapy (western medicine and Chinese medicine) for diabetic foot patients in Asia, so 

as to provide references for future research directions on drug therapy and the combination of Chinese and western medicine. Figure 3 shows the process of identifying, screening, including, and excluding literature. Ten available literature remained.

Components of Drug Therapy

After screening, 10 articles and 9 drugs for treating diabetic foot ulcers were retained. There were 5 kinds of western medicines, including Adipose-Derived Stem 

Cell–Hydrogel Complex, Hyperbaric oxygen therapy, Acellular dermal matrix, Alprostadil, Salvianolate. Chinese medicine prescription 4 kinds, including Taohong Siwu  Decoction, Simiao Yong'an Decoction, Huangqi Guizhi Wuwu Tang, Wuwei Xiaodu drink. Taohong Siwu Decoction has two pieces of literature, while other medicines only have one. Table 1 shows the nine drugs and their effects in treating diabetic foot.

Experimental design

The experimental designs were based on the route of drug use, different experimental sites, and the degree of disease. Comparing different experimental designs needed to be done from different aspects, thus the following Table 2 and Table 3 discussed the ten literature from the number of participants, age of participants, experimental location, country, degree of the lesion in patients and specific experimental operation.

Table 3: The details of all the experimental designs. 

 



                  



DISCUSSION

Nine different Chinese medicines and western medicines were used to treat diabetic foot. In the above paragraphs, different Chinese medicines and western medicines were compared one by one. Next, this section will analyze 10 articles used to determine the research direction of treating diabetic foot in the future.

In “The Potential of Allogeneic Adipose-Derived Stem 

cells - Hydrogel Complex for Treating Diabetic Foot Ulcers”6, the author said research is likely to be the first report to prove Allogeneic Adipose-Derived Stem Cell for the effectiveness of the treatment of diabetic foot ulcers. So, the study has limitations, the action mechanism of allogeneic adipose-derived stem cells still need to be further confirmed. In the study of short-duration hyperbaric oxygen therapy7, the author found that the glucose metabolism and the mechanism of improving human renal function were still unclear, and further studies were needed to determine the effect of short-duration hyperbaric oxygen therapy on diabetic foot ulcer patients. When using the xenogeneic (porcine) acellular dermal matrix to repair diabetic foot ulcers8, it can not only shorten the wound healing time, reduce the number of dressing changes, but also reduce the psychological and economic burden of patients and reduce the infection rate. At the same time, it has wide sources, simple operation, and low price, and is worthy of clinical promotion. In the study of alprostadil9, it has been determined that alprostadil has a better clinical effect and higher safety. Research shows that alprostadil is worthy of extensive application in clinical practice. In the process of studying salvia miltiorrhiza polyphenols for injection and collagen sponge10, the direct therapeutic effect of salvianolic on diabetic foot still needs further study, but it can improve microcirculation, prevent microthrombosis, regulate vascular endothelial dysfunction and other effects have been able to play a positive role in the treatment of diabetic foot. The combination of salvianolic and collagen sponge played an active role in the treatment and healing of diabetic foot. 

In the process of studying of the Taohong Siwu Decoction11, it has proved flavoured Taohong Siwu Decoction combined thioctic acid injection on diabetic foot has good effect, but the author use samples is limited, did not add the diabetic foot higher severity of patients, so in further research, more data are needed to determine the curative effect of TaohongSiwu Decoction. In the two articles of Simiao Yong'an Decoction, Jia Wei Simiao Yong an Decoction can improve the microvascular lesions of diabetic foot by repairing the damaged intima of arteries12, inhibiting inflammation13 , and so on, so that diabetic foot can be relieved. However, the literature on Simiao Yong 'an Decoction is still very limited, and the molecular mechanism of Simiao Yong 'an Decoction remains to be further studied. In the study of Huangqi Guizhi Wuwu Tang14, it was proved that Huangqi GuizhiWuwu drink could improve the vascular function and hemodynamics of the lower extremities, reduce the injury of vascular endothelial cells, and thus play a role in alleviating the progression of diabetic lower extremity vascular diseases. It is worthy of clinical promotion and application of such drugs. In the process of studying Wuwei Xiaodu drink combined with tissue engineering full-thickness skin15, it has been determined that it can improve the efficacy, improve the patient's condition and play an anti-inflammatory role without obvious adverse reactions. Therefore, it is a drug worthy of clinical promotion.

Table 4: The total effective rate of all the experiments.

                                           
                                                               
                                                                                                                                    

CONCLUSION

The purpose of the scoping review is to review the general situation of a certain research field, based on this paper, the principal contradiction discussed in this paper is comparing the researches of partial traditional Chinese medicine and western medicine treatment of the diabetic foot. Through studied and thought of these ten pieces of literature, some problems emerged obviously. The first problem was that the literature of diabetic foot in China was deficient. On the one hand, the quantity of literature in China may be considerable; on the other hand, the quality was dissatisfactory. These were two pieces of literature that had some statistical errors; both of these two pieces of literature were written by Chinese researchers. Proportionately, this kind of error maybe not only existed in the 10 literature but had a big amount in the published literature in China. The second problem was that the research of diabetic foot in Asia was not enough. According to the approach of PUBMED searches, a total of 60 articles were excluded from 33 because of geographical conditions. The third problem was that most of the literature that meets the requirements of this theme were cited fewer times, even some literature hasn’t been cited before. That confirmed the lack of research on diabetic foot in Asia from another perspective and the low quality of that literature. To sum up, this scoping review proves that there was still a big loophole in the quality of research on diabetic foot in Asia.

 

REFERENCES

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     https://doi.org/10.1155/2018/6425857

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15. Zhang GJ, Feng SJ, Wang ZX, Ai DF. Clinical observation on treatment of type 2 diabetic foot ulcer by adding or subtracting Wuwei Xiaodu Drink combined with tissue engineering full-thickness skin. Hebei J Trad Chinese Med 2019; 41(02):258-261.