Topical Esmolol Hydrochloride as a Novel Treatment Modality for Diabetic Foot Ulcers
Authors: Rastogi Ashu , Kulkarni Sudhir A. , Agarwal Sanjay , Akhtar Murtaza , Arsule Sachin , Bhamre Sudhir , Bhosle Deepak , Desai Sanjay , Deshmukh Manisha , Giriraja K. V. , Jagannath Jagannath , Kashiva Reema Yuvraj , Kesavan Rajesh , Khandelwal Deepak , Kolte Sanjay , Kongara Srikanth , Darivemula Anil Kumar , Madhusudan C. , Pyare Saheb Qureshi Mohammad Asif Haji , Ramu Muthu , Rathod Gunvant , Yalamanchi Sadasiva Rao , Shakya Shobhit , Shetty Prathvi , Singh Sudagar , Deshpande Supreet K. , Viswanathan Vijay , Unnikrishnan Ambika G. 
Published: May 2023

ImportancePreclinical and phase 1/2 studies with esmolol hydrochloride suggest its potential role in treatment of diabetic foot ulcers (DFUs).ObjectiveTo study the efficacy of topical esmolol for healing of uninfected DFUs.Design, Setting, and ParticipantsA randomized, double-blind, multicenter, phase 3 clinical trial was conducted from December 26, 2018, to August 19, 2020, at 27 referral centers across India. Participants included adults with DFUs.InterventionsParticipants were randomized after a run-in phase (1 week) to receive esmolol, 14%, gel with standard of care (SoC), SoC only, or vehicle with SoC (3:3:1 proportion) for 12 weeks (treatment phase) and followed up subsequently until week 24.Main Outcomes and MeasuresThe primary outcome was the proportion of wound closure within the 12-week treatment phase in the esmolol with SoC and SoC only groups. Analysis was conducted using an intention-to-treat safety evaluable population, full analysis set or efficacy-evaluable population, and per-protocol population comparing the esmolol plus SoC and SoC only treatment groups.ResultsIn the study, 176 participants (122 men [69.3%]; mean [SD] age, 56.4 [9.0] years; mean [SD] hemoglobin A1c level, 8.6% [1.6%]) with DFUs classified as University of Texas Diabetic Wound Classification system grade IA and IC (mean [SD] ulcer area, 4.7 [2.9] cm2) were randomized to the 3 groups. A total of 140 participants were analyzed for efficacy. The proportion of participants in the esmolol with SoC group who achieved target ulcer closure within 12 weeks was 41 of 68 (60.3%) compared with 30 of 72 (41.7%) participants in the SoC only group (odds ratio [OR], 2.13; 95% CI, 1.08-4.17; P = .03). A total of 120 participants completed the end of study visit which were analyzed. Target ulcer closure by the end of the study (week 24) was achieved in 44 of 57 (77.2%) participants in the esmolol with SoC group and 35 of 63 (55.6%) participants in the SoC only group (OR, 2.71; 95% CI, 1.22-5.99; P = .01). The median time for ulcer closure was 85 days for the esmolol with SoC group and was not estimable for SoC only group. Significant benefits of Esmolol with SoC were seen in patients with factors that impede the healing of DFU. Treatment-emergent adverse events were noted in 18.8% of the participants, but most (87.3%) of these events were not attributable to the study drug.Conclusions and RelevanceIn this multicenter, randomized, double-blind clinical trial, the addition of esmolol to SoC was shown to significantly improve the healing of DFUs. With these results, topical esmolol may be an appropriate addition to SoC for treating DFUs.Trial RegistrationClinicalTrials.gov Identifier: NCT03998436; Clinical Trial Registry, India CRI Number: CTRI/2018/11/016295