The nitric oxide connection: hyperbaric oxygen therapy, becaplermin, and diabetic ulcer management.

Clinical experience with adjunctive hyperbaric oxygen therapy in the treatment of diabetic ulcers has shown that wound hyperoxia increases wound granulation tissue formation and accelerates wound contraction and secondary closure. In addition to wound hyperoxia, increased wound nitric oxide production caused by hyperbaric oxygen therapy also appears to be important for successful diabetic wound repair. The results of a preliminary retrospective study suggest that nitric oxide production is reduced in the nonhealing diabetic wound, and that topical becaplermin therapy is effective only when wound nitric oxide production deficiency is corrected. In addition, the data suggest that below a critical level of endogenous nitric oxide production, diabetic ulcer repair may not be achieved. Under this hypothesis, diabetic patients with chronic, nonhealing ulcers that respond to becaplermin should have substantially increased endogenous nitric oxide production compared with those ulcers that do not respond to becaplermin. The results of a preliminary clinical study support the use of combined therapy using topical becaplermin and hyperbaric oxygen therapy as a means of successfully treating the chronic diabetic ulcer patient with deficient nitric oxide production and local wound hypoxia.