Rise in diabetic amputations amid Italian pandemic lockdown

Current COVID-19 pandemic has brought monumental changes and challenges in our society, unprecedented in modern history and comparable only to those caused by the Spanish flu outbreak. The pandemic has not only changed the way we work, do business, and socialize, but also how we provide healthcare.

Telemedicine is one of the obvious go-to solutions, but it is utilized far too sparsely to have had a meaningful impact on the lives of patients with COVID-19 and other, primarily those with chronic conditions, who bore the brunt of inefficient (in addition to general lack of resources) healthcare protocols and workflows. Many were hindered in accessing healthcare services and consequently suffered accordingly. Among those were also diabetics in Italy during the last lockdown who had higher rates of amputation than they would have otherwise.

In this blog you will learn:

• Why is diabetes a risk factor for amputation?
• Why were Italian diabetics at a higher risk of amputation during the lockdown?

Why is diabetes a risk factor for amputation?

Deleterious effects of diabetes mellitus (both type 1 and type 2) are multifaceted and are affecting a growing number of patients. There were an estimated 463 million individuals with diabetes in 2019 and it is estimated that their numbers will continue growing: to 578 million by 2030 and to 700 million by 2045 [1].

They have higher all-cause mortality and mortality due to the kidney disease, chronic lower respiratory diseases (including COVID-19), influenza and pneumonia and cardiovascular conditions [2, 3, 4]. One of the latter is also peripheral artery disease (PAD), which significantly increases the likelihood of intermittent claudication (decreased quality of life), lower extremity ulceration, gangrene, and the risk of amputation [5, 6, 7].

It is estimated that those with both PAD and diabetes are at 5 to 15-times greater risk of major amputation than non-diabetic PAD patients [8]. More specifically, it is estimated that about 50 % of patients with critical limb ischemia (CLI), the advanced stage of PAD associated with lower-extremity amputation and significant mortality, also have diabetes, and they fare worse (more severe CLI) than non-diabetics [9, 10, 11]. However, the diagnosis of comorbid PAD is not the only factor contributing to higher rates of gangrene and amputation since both can also be caused by a lack of (professional) care of diabetic foot and other preventive treatments. This was also highlighted by an Italian study that found higher rates of amputation in diabetics who were given inadequate care due to the nationwide COVID-19 lockdown [12].

Why were Italian diabetics at a higher risk of amputation during the lockdown?

Researchers compared amputation rates and between patients admitted to the Division of Endocrinology and Metabolic Diseases at the Teaching Hospital of University of Campania “Luigi Vanvitelli” in Naples in 2020 and in 2019 (pre-COVID-19) [12]. The 2019 group (38 patients) and 2020 group (25 patients) were of similar age and had comparable diabetes duration and HbA1c levels [12]. However, there was a higher male-to-female ratio in the 2020 group (the 2019 group also exhibited that but to a lesser degree), they were less likely to be coming from an outpatient clinic (16 % vs 45 % for 2019 group) and far more likely to be admitted for emergency treatment (76 % vs 26 % for 2019 group) [12].

Far more profound were differences in the prevalence of gangrene and amputation rates [12]. The 2020 group suffered more than 2-times higher (64 % vs 29 % for 2019 group) prevalence of gangrene and a more than three-fold increase in amputations (60 % vs 18 %) [12]. There were no differences in the number of revascularization and other surgeries [12]. Causation between the COVID-19 lockdown and subsequent interruption of diabetic foot care and lower limb preservation pathways leading to consequences is therefore far from tentative and a reminder of the need for proper and timely management of patients with diabetic foot.

COVID-19 pandemic has had a significant deleterious effect on the lives of Italian diabetic patients, and it is highly likely that the same could be said for diabetics in other countries and regions, but whose travails went unpublished.