The Effect of Combination Therapy of Oral MB and PRP-FG in Patients With Non-healing Diabetic Foot Ulcer

Study Overview
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Brief Summary
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The aim of this study is to evaluate the chance of non-healing diabetic foot ulcers repair by improving the condition of lack of oxygen or hypoxia in the wound area caused by diabetes using methylene blue along with the use of platelet-rich plasma-fibrin glue as an effective treatment for wound healing.

Detailed Description
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The current study assesses the effects of methylene blue along with the use of platelet-rich plasma-fibrin glue on wound healing in patients with nonhealing diabetic foot ulcers (non-healing DFU). This randomized controlled trial is performed on 20 patients with non-healing DFU. Patients were treated with PRP-FG dressing plus 200 ml of oral methylene blue dissolved in milk(intervention group) or PRP-FG dressing plus placebo (200 ml of milk) (control group) for 4 weeks.

Official Title
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The Effect of Combination Therapy of Oral Methylene Blue and Platelet-rich Plasma-fibrin Glue in Patients With Non-healing Diabetic Foot Ulcer: a Pilot Study

Conditions
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Diabetic Foot Ulcers, Diabetic Wound

Intervention / Treatment
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* Drug: Methylene Blue
* Other: Milk (control)
* Drug: Methylene Blue and Platelet-Rich Plasma-Fibrin Glue
* Other: Milk and Platelet-Rich Plasma-Fibrin Glue (control)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Having a Diabetic ulcer grade II and IV based on Wagner's classification on the sole, medial, or lateral part of the foot (including all surfaces of the toes) Having a single ulcer on the feet and extremities (toes, soles, heels) with no significant reduction in ulcer size (<20%) despite the use of best treatment methods for at least four weeks If there is more than one non-healing wound, choose the largest wound The size of the wound surface (length × width) between 2 cm2 and 20 cm2 No smoking, alcohol, and drug addiction based on the patient's self-report Not taking drugs that may interfere with wound healing, such as Corticosteroids, immunosuppressants, and cytotoxic agents Not having a concurrent chronic disease that may cause problems in wound healing, such as cancers, vasculitis, no history of known severe kidney, liver, and heart disease, such as liver cirrhosis, active hepatitis, dialysis, etc. Not taking antidepressants Insensitivity to milk lactose Not having Glucose 6-phosphate dehydrogenase (G6PD) deficiency Confirmed, informed, signed consent form Ankle Brachial Index (ABI) higher than or equal to 0.7 Exclusion Criteria: Do not be treated with methylene blue The confirmed presence of osteomyelitis, or if there is suspicion of osteomyelitis The subject is pregnant or intends to become pregnant during the test period The patient is known to have mental, developmental, physical, and emotional disorders The occurrence of certain medical conditions The presence of a wound with a clear and severe infection, which is characterized by significant purulent secretions or extensive cellulitis, or gangrene requiring amputation Evidence of venous, ischemic, neurotrophic ulcers (numbness, tingling, lack of Achilles tendon reflex) and traumatic wounds in the patient Failure to refer the patient more than two times to the mentioned center for follow-up and dressing change Hypersensitivity reaction to methylene blue Platelet count less than 100,000 The patient's lack of consent to continue cooperation
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Factorial Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Methylene Blue<br>The first intervention group (group A) includes diabetic patients with chronic foot ulcers who, despite common treatments, will be undergone oral methylene blue intervention (70 mg in 200 ml of milk) for 4 weeks. | Drug: Methylene Blue<br>* The first intervention group includes diabetic patients with chronic foot ulcers who, despite common treatments, will be undergone oral methylene blue intervention for 4 weeks.<br>* Other names: Methylthioninium chloride;|
| Experimental: Milk (control)<br>Patients with non-healing Diabetic Foot Ulcers only will receive 200 ml of milk for 4 weeks. | Other: Milk (control)<br>* Group B will receive 200 ml of milk for 4 weeks.<br>* Other names: Placebo;|
| Experimental: Methylene Blue and Platelet-Rich Plasma-Fibrin Glue<br>Patients with non-healing Diabetic Foot Ulcers will treat with PRP-Fibrin-Glue plus oral methylene blue (70 mg in 200 ml of milk) for 4 weeks. | Drug: Methylene Blue and Platelet-Rich Plasma-Fibrin Glue<br>* Group C will be undergone synergistic 4-week treatment with oral methylene blue and fibrin glue.<br>* Other names: Methylthioninium chloride and PRP-Fibrin Glue;|
| Experimental: Milk and Platelet-Rich Plasma-Fibrin Glue (control)<br>Patients with non-healing Diabetic Foot Ulcers will be treated with PRP-Fibrin-Glue and 200 ml of milk for 4 weeks. | Other: Milk and Platelet-Rich Plasma-Fibrin Glue (control)<br>* Group D will be treated only with fibrin glue and 200 ml of milk for 4 weeks.<br>* Other names: Placebo;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The healing rate of the ulcer | Measurement of wound area with a ruler | 4 weeks | 
| Wound Size | Wound size will be measured with a ruler for length, and width as well as with digital imaging. Wound size will be assessed in digital images taken of the wound. | 4 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| TcPO2 at baseline and after the intervention | Transcutaneous oxygen tension (TcpO2) provides information about blood perfusion in the tissue immediately below the skin. (blood pressure, measured in millimeters of mercury (mmHg)) | 4 weeks | 
| Oxygen saturation at baseline and after the intervention | Blood must contain a normal concentration of hemoglobin. that hemoglobin must be >95 % saturated with oxygen in arterial blood (sO2(a) >95 %) | 4 weeks | 
| Blood pressure (systolic and diastolic) | The pressure of the blood in the circulatory system | 4 weeks | 
| The resting systolic toe pressure (TP) at baseline and after the intervention | The toe cuff with the sphygmomanometer is slowly inflated until the waveform flattens (generally between 150-200 mmHg), then is inflated a further 20 mmHg. The cuff is slowly released at a rate of 2-5mmHg per second. The first regular cyclical waveform is considered the toe systolic pressure. | 4 weeks | 
| Serum IL-1β levels at baseline and after the intervention | Analysis of serum interleukin-1β levels | 4 weeks | 
| Serum MCP-1 levels at baseline and after the intervention | Analysis of serum monocyte chemoattractant protein-1 (MCP-1) levels | 4 weeks | 
| Serum TNF-α levels at baseline and after the intervention | Analysis of serum tumor necrosis factor α (TNFα) levels | 4 weeks | 
| Serum IL-6 levels at baseline and after the intervention | Analysis of serum interleukin-6 (IL-6) levels | 4 weeks | 
| Serum HIF-1α levels at baseline and after the intervention | Analysis of serum hypoxia-inducible factor 1-alpha (HIF-1α) levels | 4 weeks | 
| Serum FBS levels at baseline and after the intervention | Analysis of serum fasting blood sugar (FBS ) levels | 4 weeks | 
| Serum Insulin levels at baseline and after the intervention | Analysis of Insulin levels | 4 weeks | 
| Lipid Profile at baseline and after the intervention | Serum Triglyceride, Cholesterol, HDL, LDL, VLDL | 4 weeks | 
| Serum Urea at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Serum Creatinine at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Serum total bilirubin at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Serum Vitamin D levels at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| HbA1c at baseline and after the intervention | Glycated hemoglobin | 4 weeks | 
| Serum Albumin (Alb) levels at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Uric Acid levels at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Serum Homocysteine levels at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Serum ALT (alanine transaminase) levels at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Serum AST (Aspartate Transferase) levels at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Serum ALP (alkaline phosphatase) levels at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Serum Met Hemoglobin levels at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Serum Hemoglobin (Hgb, Hb) levels at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Serum white blood cells (WBCs) levels at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Serum total Lymphocyte levels at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Platelet count at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Nitric oxide blood at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Serum lactate dehydrogenase (LDH) levels at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Serum Erythrocyte Sedimentation Rate (ESR) levels at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Serum C-Reactive Protein (CRP) levels at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 
| Neutrophils count at baseline and after the intervention | In a quantitative laboratory method | 4 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Platelet-Rich Plasma-Fibrin Glue, DFU, Methylene blue, Non-healing Diabetic Foot Ulcers