Diabetes

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Sunday, May 25, 1997 18 Iyar 5757

New Therapy For Diabtics Saves Limbs

(May 13) Say "diabetes" and what comes to mind is insulin injections and observing a strict diet. But non-insulin-dependent diabetes (Type II) - which affects a growing number of middle-aged and elderly people - is a highly complicated, potentially dangerous condition that, if not properly treated, can end in blindness, heart disease, limb amputation and death.

"Diabetic foot" is one of the most neglected subjects in geriatric medicine, says Dr. Alexander Olshanyetsky, a vascular expert who moved here from Estonia, 13 years ago. Nearly 10 percent of all Israelis suffer from diabetes, and each year, 1,000 of them undergo amputations of toes, feet and legs due to complications of the disease. The condition is a great burden not only upon the patient, who is suddenly less than whole, but on their families, who feel as if they are sliding down a slippery slope to watch their loved one's growing disability and provide major nursing care.

After years of diabetes, the smaller arteries in the extremities become obstructed and close up, severely reducing the amount of blood that can reach the feet and toes. Peripheral neuropathy results in a burning sensation and often much pain. Bacteria enter the skin, causing the development of small wounds that fail to repair under the body's natural healing process. More infections occur, and doctors prescribe antibiotic salves.

As infections nibble away at the bone, osteoporosis can develop as well. Due to the lack of oxygen in the tissue, ischemia can lead to gangrene and unless this process is reversed, amputations are necessary, often salami-style - piece by piece - as the tissue necrotizes. The patient, one day independent and active, can overnight become weak and helpless, hospitalized so he can receive antibiotics intravenously. But, explains Olshanyetsky, if the small arteries in the foot - only a 10th to a half of a millimeter wide and only a few centimeters long - are impassable, the blood and the antibiotics it should carry cannot reach the area to promote healing. "Patients are forced to wander from one doctor to another without finding a solution. These want just to get rid of them, because in the most chronic and serious cases, they really haven't much to offer."

The Soviet-born physician has teamed up with Dr. Mordechai Halperin, a Jerusalem rabbi, gynecologist, fertility expert and medical ethicist who a few years ago left his position at Hadassah-University Hospital to set up his own male fertility clinic. Together, they developed the unique method of injecting into the foot vasoactive medications (such as prostaglandins and papavarin) of the same type used to expand penile blood vessels to treat impotence. The injections, which are carried out under the guidance of a special ultrasound method to pinpoint the ideal location for the shots, are given gradually over a period of weeks or months.

The result of this breakthrough is a chain of private Diabetic Foot Clinics in Jerusalem, Ramat Gan, Haifa, Beersheba, Ashdod and Arad for diabetic-foot patients. Halperin runs the Jerusalem clinic on his own, but he and Olshanyetsky, who works in Ramat Gan, consult with each other on some cases.

"If not enough blood is reaching the foot, the standard procedure in hospital surgical departments is to perform angioplasty [inserting a balloon on the end of a catheter through the leg arteries] to expand the blood vessels," Halperin explains. "If successful, an Echo Doppler scan shows the pulse in the large arteries has improved. But in some cases, improved circulation reverses itself as the blood vessels close up again. In any case, the catheter can't reach into the small arteries in the foot, so the improved pulse doesn't necessarily mean the wounds will heal." Olshanyetsky adds that many patients undergo an arterial bypass (taking a vein from elsewhere in the leg to replace the narrowed segment of leg artery), but this too doesn't always bring about an improvement in the lower foot. "This is mechanical intervention. We decided to use a physiological and pharmacological intervention, and it solves the problem in the majority of cases; it fails if the small arteries have closed up irreversibly."

Although Halperin is not a vascular surgeon, as a male fertility expert he has much experience with vasodilators that expand the blood vessels in the penis to allow an erection, and these drugs can be used safely elsewhere in the body as well.

Some 500 patients suffering from neuropathy or vascular occlusion have been treated so far, with 70% to 80% success, says Olshanyetsky. Of 85 diabetics suffering from wounds in their feet, none have had to undergo an amputation so far, and side effects have been "minimal."

The treatment, whose cost is not included in the health funds' basket of health services, ranges from $1,000 to $3,000.

One prominent physician, F.T., who is himself a diabetic and suffered from serious foot infections, heard of the injections and decided to try the technique. To his relief, they have all cleared up and he continues to work normally. "Prostaglandins have been known to medicine for years," says F.T., who heads a hospital department, "but their use in expanding small arteries in the diabetic foot is really Olshanyetsky and Halperin's innovation."

Contrary to common practice, the two doctors have not yet published their discovery in medical journals either here or abroad. "Publication at this stage," they say, "could cause Israel a great financial loss. We believe that the technique we developed will bring into this country hundreds of thousands of patients unable to get the treatment anywhere else in the world. We may also offer franchises to other institutions to use the technique."