Using Becaplermin Gel With Collagen to Potentiate Healing
Using Becaplermin Gel With Collagen to Potentiate Healing
Use of becaplermin gel (Regranex®, Johnson & Johnson Wound Management, Somerville, New Jersey) to heal chronic wounds has been reported with varying results in the wound healing literature. Early in the use of becaplermin gel on chronic wounds, the authors noted some difficulty in changing the dressing twice a day following the original manufacturer guidelines. To reduce the number of dressings and maintain moist healing, and after use of a number of other products, the authors began to use collagen products as part of the dressings. Collagen products (collagen-alginate, Fibracol®, Johnson & Johnson Wound Management, Somerville, New Jersey; and small intestinal submucosa [SIS], Oasis®, Healthpoint Ltd., Fort Worth, Texas) were slightly moistened with saline and initially applied over becaplermin gel on 36 chronic leg wounds in 36 patients (18 collagen-alginate, 18 SIS). All patients had been treated with collagen dressings in a moist environment and, at a separate time, becaplermin gel for at least three weeks without response. Dressings were changed every three days. At each dressing change, becaplermin was reapplied to the wound. SIS was replaced when it appeared not to be present in at least half the wound, and on the average, this was every nine days for this collagen product. Using collagen-alginate, the moistened collagen was re-applied to the wound at each dressing change. Twenty-four patients healed without further intervention, and 10 more healed over the next three months to the point of being able to be closed with surgical intervention (skin grafts). Two patients remained unhealed, and both were patients with renal failure. Use of becaplermin gel with a collagen product in concert with good wound healing practices may further induce chronic wounds to heal and, at the same time, reduce frequency of dressing changes. Whether the positive healing effects come from stimulation of healing by becaplermin while blocking protease activity by the collagen or by other yet to be elucidated means cannot be answered by this case series. This report does provide an alternative way to use becaplermin gel with collagen products that exerts a positive effect on wound healing.
Becaplermin gel (Regranex®, Johnson & Johnson Wound Management, Somerville, New Jersey) a genetically engineered, platelet-derived growth factor (PDGF) that mimics human PDGF, has been approved for use in diabetic lower-extremity ulcers since 1997. Becaplermin also appears to be effective in nondiabetic patients with chronic wounds, and it is frequently used in these patients. Becaplermin gel's effect on chronic wounds is often less than stunning, often taking months to show a progression to healing in many series. The cost for a 15-ounce tube varies from $350.00 to $500.00 in the authors' area (Southern California).
Early in the use of becaplermin gel on chronic wounds of the legs, the authors were thwarted by the original instructions to change the dressing every 12 hours. In this outpatient setting, many patients were unable or unwilling to cooperate with this plan. As a result, the authors noted that many wounds would dry out or become contaminated before the next visit. Consequently, the authors began to try alternate methods for application of becaplermin. The original concept in the authors' use of collagen with becaplermin was to provide a longer-lasting, moist dressing that would protect the becaplermin gel and the wound. Extraneous collagen often derived from bovine or swine sources has been used for decades as an adjunct for wound healing. Exact mechanisms of collagen's assistance in wound healing remain to be precisely defined, but its useful effects are well known. The authors felt that collagen might also potentiate the duration of effect of becaplermin by providing a slower release of becaplermin and by slowing the destruction of the becaplermin.
All formulations of collagen did not appear equally effective when used in this manner, and the authors chose to use two collagen products with becaplermin gel based on preliminary trial and error. These preparations were Fibracol Plus® (collagen-alginate, Johnson & Johnson Wound Management, Somerville, New Jersey) and Oasis® (small intestinal submucosa [SIS], Healthpoint, Ltd., Fort Worth, Texas). The collagen-alginate product is a combination of 10-percent alginate and 90-percent collagen, and SIS is derived from submucosa of porcine small intestine. As this treatment appeared efficacious in diabetic patients, the authors expanded the treatment to include nondiabetic patients as well. This was done with the provision that the patients had not responded to collagen or becaplermin gel alone and had other known factors that interfered with wound healing (e.g., ischemia, poor nutrition, pressure, and infection) corrected as much as possible.
All of the patients had wound care involving maintenance debridement and moist dressings and failed to show signs of healing. In some instances, ultrasound, electrical stimulation, hyperbaric oxygen, and vacuum-assisted closure had also been used without a significant healing response. Criteria of a significant healing response were decrease in wound size, proliferation of granulation tissue, absence of heavy or foul discharge, and absence of progressive or recurring necrosis.
Use of becaplermin gel (Regranex®, Johnson & Johnson Wound Management, Somerville, New Jersey) to heal chronic wounds has been reported with varying results in the wound healing literature. Early in the use of becaplermin gel on chronic wounds, the authors noted some difficulty in changing the dressing twice a day following the original manufacturer guidelines. To reduce the number of dressings and maintain moist healing, and after use of a number of other products, the authors began to use collagen products as part of the dressings. Collagen products (collagen-alginate, Fibracol®, Johnson & Johnson Wound Management, Somerville, New Jersey; and small intestinal submucosa [SIS], Oasis®, Healthpoint Ltd., Fort Worth, Texas) were slightly moistened with saline and initially applied over becaplermin gel on 36 chronic leg wounds in 36 patients (18 collagen-alginate, 18 SIS). All patients had been treated with collagen dressings in a moist environment and, at a separate time, becaplermin gel for at least three weeks without response. Dressings were changed every three days. At each dressing change, becaplermin was reapplied to the wound. SIS was replaced when it appeared not to be present in at least half the wound, and on the average, this was every nine days for this collagen product. Using collagen-alginate, the moistened collagen was re-applied to the wound at each dressing change. Twenty-four patients healed without further intervention, and 10 more healed over the next three months to the point of being able to be closed with surgical intervention (skin grafts). Two patients remained unhealed, and both were patients with renal failure. Use of becaplermin gel with a collagen product in concert with good wound healing practices may further induce chronic wounds to heal and, at the same time, reduce frequency of dressing changes. Whether the positive healing effects come from stimulation of healing by becaplermin while blocking protease activity by the collagen or by other yet to be elucidated means cannot be answered by this case series. This report does provide an alternative way to use becaplermin gel with collagen products that exerts a positive effect on wound healing.
Becaplermin gel (Regranex®, Johnson & Johnson Wound Management, Somerville, New Jersey) a genetically engineered, platelet-derived growth factor (PDGF) that mimics human PDGF, has been approved for use in diabetic lower-extremity ulcers since 1997. Becaplermin also appears to be effective in nondiabetic patients with chronic wounds, and it is frequently used in these patients. Becaplermin gel's effect on chronic wounds is often less than stunning, often taking months to show a progression to healing in many series. The cost for a 15-ounce tube varies from $350.00 to $500.00 in the authors' area (Southern California).
Early in the use of becaplermin gel on chronic wounds of the legs, the authors were thwarted by the original instructions to change the dressing every 12 hours. In this outpatient setting, many patients were unable or unwilling to cooperate with this plan. As a result, the authors noted that many wounds would dry out or become contaminated before the next visit. Consequently, the authors began to try alternate methods for application of becaplermin. The original concept in the authors' use of collagen with becaplermin was to provide a longer-lasting, moist dressing that would protect the becaplermin gel and the wound. Extraneous collagen often derived from bovine or swine sources has been used for decades as an adjunct for wound healing. Exact mechanisms of collagen's assistance in wound healing remain to be precisely defined, but its useful effects are well known. The authors felt that collagen might also potentiate the duration of effect of becaplermin by providing a slower release of becaplermin and by slowing the destruction of the becaplermin.
All formulations of collagen did not appear equally effective when used in this manner, and the authors chose to use two collagen products with becaplermin gel based on preliminary trial and error. These preparations were Fibracol Plus® (collagen-alginate, Johnson & Johnson Wound Management, Somerville, New Jersey) and Oasis® (small intestinal submucosa [SIS], Healthpoint, Ltd., Fort Worth, Texas). The collagen-alginate product is a combination of 10-percent alginate and 90-percent collagen, and SIS is derived from submucosa of porcine small intestine. As this treatment appeared efficacious in diabetic patients, the authors expanded the treatment to include nondiabetic patients as well. This was done with the provision that the patients had not responded to collagen or becaplermin gel alone and had other known factors that interfered with wound healing (e.g., ischemia, poor nutrition, pressure, and infection) corrected as much as possible.
All of the patients had wound care involving maintenance debridement and moist dressings and failed to show signs of healing. In some instances, ultrasound, electrical stimulation, hyperbaric oxygen, and vacuum-assisted closure had also been used without a significant healing response. Criteria of a significant healing response were decrease in wound size, proliferation of granulation tissue, absence of heavy or foul discharge, and absence of progressive or recurring necrosis.
Source...