A 62-year-old male, married, retired, with type 2 diabetes for more than 15 years, background to rheumatoid arthritis and myocardial revascularization, with no history of using alcohol or tobacco, without neuropathy, feeling pain in right foot which showed signs of dry necrosis in the plate and in the digital pulp of the third finger, and partial necrosis in the hallux reported. He Presented with distal pulses in the finger extremities, without fever, heartbeat of 80/min fc, and Pa 13 x 9 and was attended at the Diabetic Foot Treatment Center with diagnosis of type II diabetes and ischemic diabetic foot. He presented with progressive and painful necrotic plaques in the right hallux and 3rd right foot pod. The color of the feet was purple with fuming appearance. In terms of background, the patient reported treatment with a rheumatologist at the Hospital das Clinicas in Sao Paulo due to arthritis of the hands and coronary stent placement for 6 months at INCOR-SP. He was being medicated with prednisone, clopidogrel, and metformin.
After clinical evaluation, he was medicated with Cilostazol 50, and an arterial echo Doppler of the lower limbs was requested. This examination concluded that the arterial trunks had vascular patency with three-phase flow. There was a minor, noticeable improvement of the right toes after two months of treatment with Cilostazol but with worsening of the contralateral toes. There were fixed cyanosis and resting pain of the 3rd and 4th toes of the left foot. Even an intensive care treatment by photodynamic therapy (PDT) did not improve the condition of the diabetic foot. After consulting his cardiologist to authorize the use of SC, this drug was administered at the daily dose of 50 mg. This treatment was maintained for 10 months, with remission of the endpoint ischemia. The patient reported feeling well, and PDT started to respond well. After 5 PDT sections, feet lesion healed and the patient regained his colored feet and reported no pain (Figure 1).
One year after discharge, the patient returned again with lesion in his 1st left toe, ischemia in the 2nd right toe, with a necrotic plaque and ulcerated digital pulp, a lot of resting pain, and left lateral hallux ulcer. SC was once again administered, this time in doses of 50 mg every 12 hours (100 mg/day). After 3 months and 6 PDT sections, the 1st left toe had already healed, but the patient started to report hypoglycemia attacks. The use of Metformin and fasting was discontinued, as long as glucose levels were kept between 82 and 93 mg/dl, and SC was reduced again to 50 mg. The treatment of the 2nd finger, which was initially ulcerated, was finalized by PDT, and the patient was discharged.
During this relatively long period (more than two years), glycemia was obtained daily throughout several months, and average values are shown in Table 1. It is clear that SC allowed for a reduction and stabilization of glycemic values, with the extra benefit of having improved also the microvasculature, as indicated by the cure of the diabetic foot. It is also possible to note that there is an effect of the dose of SC, since during the 100 mg/day period, glycemia was significantly lower than in the other three periods in which the patient received a SC dose of 50 mg/day. However, as mentioned above, patient 1 under 100 mg/day of SC had an important hypoglycemic event, which was not observed at the 50 mg/day dose.