CME INDIA Presentation by Dr. Bijay Patni, Diabetologist Physician, Kolkata.

Diabetic foot- a disease with considerable health care burden

  • Foot problems – important cause of morbidity in patients with diabetes mellitus.
  • Lifetime risk of a foot ulcer (diabetic patient) – 34%.
  • ~ 50% diabetic foot ulcers develop infection – lead to sepsis, gangrene, amputation, and death.
  • Large days of inpatient stays, high rate of hospital readmission, associated with a 2.5-fold risk of death compared with patients with diabetes without foot ulcers.
  • Foot amputations – required in up to 20 percent of diabetic foot ulcers.
  • Every 20 seconds, a lower limb is amputated somewhere in the world due to diabetic foot infection (DFI).
  • DF: The major reason for high incidence of amputations globally.1
  • A macro-vascular complication associated with increased morbidity and mortality.2
  • Classically DFI involves any soft tissue or bone infection below the malleoli.1
  • Treatment negligence could lead to increased severity and complications.1
  • Spectrum of complications includes superficial cellulitis to chronic osteomyelitis and gangrene necessitating lower limb amputation.2

Prevalence3

  • Globally prevalence of DFI ranges from 1.5%- 16.6%.
  • In India, the prevalence is 11.6%.
  • Risk factors for DFI: Smoking, diabetic retinopathy, male gender.

Diabetes foot care is critical for preventing foot ulcers and amputations

  • Routine foot exams, proper footwear, and careful hygiene can protect the feet.
  • Early treatment of foot problems is essential.

Screening for diabetic foot disease

Who should be screened?

  • All patients with diabetes should be screened for polyneuropathy at the time of diagnosis of type 2 diabetes and five years after the diagnosis of type 1 diabetes.
  • Patients with prediabetes who have symptoms of polyneuropathy should also be screened.
  • After initial screening – all patients with type 2 or type 1 diabetes who do not have polyneuropathy should be screened at least annually for the development of neuropathy.

Screening assessment (elements):

  • A careful history.
  • Assessment of small nerve fiber function by testing thermal or pinprick sensation and light touch perception with a 10 g monofilament on the dorsal aspect of the distal great toe.
  • Assessment of large nerve fiber function by testing vibration sensation with a 128 Hz tuning fork, proprioception (joint position sensation), and deep tendon reflexes at the ankle as compared with more proximal locations.

Patient education

Diabetes Foot Care - What Physicians Must Know?

Pathophysiology

Diabetic foot infection is a result of complex interplay between neuropathy, peripheral arterial diseases, foot deformities and infections2

Diabetes Foot Care - What Physicians Must Know?

Courtesy: Tarun Sahni and Gupta Shweta and Verma Sapna, Hyperbaric oxygen therapy heals diabetic wounds. Apollo Medicine-2014(11)

Foot care for high-risk patients

  • Along with the foot care measurements, a variety of strategies utilize pressure sensors, temperature measurements, and telemetry for monitoring very high-risk patients and may help with early detection and prevention.
    • Customized, pressure-relieving footwear also can help reduce the risk of recurrent foot ulcers.
    • A comprehensive foot examination should be performed annually on patients with diabetes to identify risk factors predictive of ulcers and amputation.
    • Counselling regarding preventive foot care should be given to any patient whose feet are at risk for ulceration.
  • Patients should be referred to a foot care specialist if they have an existing foot ulcer, or if they are at particularly high risk for foot ulceration due to the following risk factors:
    • A previous history of foot ulceration or amputation.
    • Loss of protective sensation and/or neuropathic foot deformities.
    • Peripheral vascular disease.

Comprehensive foot examination and risk assessment

Diabetes Foot Care - What Physicians Must Know?

Risk Classification

Diabetes Foot Care - What Physicians Must Know?

Preventive foot care

Advice for prophylactic foot care should be given to all patients (important in patients with existing neuropathy).
Avoid smoking.
Avoid going barefoot, even at home, and especially on hot decks and hot sand.
Test water temperature before stepping into a bath.
Trim toenails to the shape of the toe, and remove sharp edges with a nail file; do not cut cuticles.
Wash in lukewarm water, dry thoroughly (including between the toes), and check feet daily.
Shoes should be snug, but not tight, and customized if feet are misshapen or there is a history of ulcers.
Socks should fit and be changed daily.

Diabetic neuropathy

  • Most common painful complication of diabetes.
  • May be present even at the time of first diagnosis in type 2 diabetes & even in pre diabetic condition.
  • Most common cause of neuropathy world wide.
  • Type 2 diabetes: 30-40 % have neuropathy.
  • Type 1 diabetes: 28 % (EURODIAB).

Why is identifying and treating neuropathy important?

  • Quality of Life issues.
  • Foot ulcers.
  • Foot deformities.
  • Charcot’s foot.
  • Non traumatic amputations.

Risk Factors

  • Hyperglycemia.
  • Damage to blood vessels.
  • Mechanical injury to nerves.
  • Autoimmune factors.
  • Genetic susceptibility.
  • CV Disease.
  • Lifestyle factors:
    • Smoking.
    • Alcohol.
    • Diet.
    • Dyslipidemia.
    • Obesity.

Charcot Arthropathy (Diabetic Neuropathic Arthropathy)

  • A late complication of diabeitc neuropathy – characterized by collapse of the arch of the midfoot and abnormal bony prominences.
  • Autonomic neuropathy associated with Charcot arthropathy can lead to:
    • Diminished or absent sweating: the skin of the feet remains dry and tends to become scaly and cracked – ALLOWING infection to penetrate below the skin.
    • Lack of autonomic tone in the capillary circulation: shunting of blood from arteries directly into veins, bypassing the tissues that need nutrition – resulting in a foot that feels warm and has distended veins and bounding pulses.

The foot is vulnerable to local “microvascular” gangrene, will heal very poorly and slowly, and will be less able to resist infection.

Approach to the patients to identify the risk for foot ulceration

  • Diabetic Patients – examined to identify the risk for foot ulceration.
  • Feet – visually inspected at each routine visit to identify problems with nail care, poorly fitting footwear resulting in barotrauma, fungal infections, and callus formation – result in more severe foot problems.
  • History:
    • Duration of diabetes
    • Overall glycaemic management.
    • Presence of micro or macrovascular disease.
    • History of prior foot injury resulting in deformities or prior ulcers.
    • Lower limb vascular bypasses or amputation.
    • Presence of claudication.
    • History of cigarette smoking.
  • Comprehensive foot examination (Primary Care Setting):
    • Inspection.
    • Assessment of pedal pulses.
    • Testing for loss of protective sensation.

Evaluation of peripheral artery disease 

  • Clinical evidence of peripheral artery disease – ABI testing – detect macrovascular, but not microvascular, peripheral artery disease.
    • Patients with extensive vascular calcification and noncompressible arteries – false positive elevations in the ABI.
    • A low ABI in the absence of a foot ulcer does not correlate with the risk of future foot ulceration.
    • A low ABI in the presence of a foot ulcer – prognosis will be improved with reconstructive vascular surgery.
    • A low ABI also indicates more generalized arteriosclerosis and is associated with an increased risk of cardiovascular death.

Multidisciplinary management

Diabetes Foot Care - What Physicians Must Know?

Treatment – Painful neuropathy

Diabetes Foot Care - What Physicians Must Know?
Diabetes Foot Care - What Physicians Must Know?

Non-pharmacological management of diabetic neuropathy

  • Infrared therapy.
  • Shoe magnets.
  • Exercise.
  • Acupuncture.
  • External stimulation (transcutaneous electrical nerve stimulation TENS).
  • Spinal cord stimulation.
  • Biofeedback and behavioural therapy.
  • Surgical decompression.

Combination Therapy

  • Combination of 2 first-line medications may be more efficacious than either medication alone.
  • Combination pharmacotherapy may:
    • Improve the analgesic efficacy.
    • Reduce side effects of individual drugs.
    • But not enough evidence exists to recommend a specific drug combination.
  • Frequent strategy in clinical practice.
Diabetes Foot Care - What Physicians Must Know?

Treatment of Foot Ulcer

Diabetes Foot Care - What Physicians Must Know?

Wound Care

Day 1: Clean wounds with saline and cover with clean dressing.
Day 2 to 6: Change dressings daily and check for signs of infection.
Week 1 to 6: Gradually decrease dressing changes as wound heals.
Ongoing: Keep pressure off wounds with special shoes and socks.

Empirical Antibiotic Alert

  • Irrespective of the severity of the disease, the current recommendation for treating infections in diabetic foot ulcers (DFUs) is to obtain a deep tissue culture to guide the choice of antimicrobial therapy. Both the Infectious Diseases Society of America (IDSA) and the International Wound Group Diabetic Foot (IWGDF) advise against using a superficial wound swab for microbial evaluation of infection.
  • In cases where cultures cannot be obtained, empirical antibiotic selection should be directed towards the most likely pathogens, such as Staphylococcus aureus and Streptococcus spp., taking into account the patient’s medical history and associated comorbidities.
  • However, it is worth noting that IDSA recommendations, which are based on low-quality evidence, suggest that culture-guided therapy may be deemed unnecessary for mild DFU infections.

Wound Control

Diabetes Foot Care - What Physicians Must Know?

11 Commandments of Diabetic Foot Care

1. DO NOT walk barefoot.
2. INSPECT the feet daily for blisters, wounds, bleeding, smell, increased temperature at pressure point of feet and edema.
3. AVOID shoes with narrow toe box, high heels or have straps with no back support.  Always wear footwear with socks with loose elastic. Buy shoes always in evening after consulting your doctor. Clean inside the shoes before wearing it.
4. DO NOT apply hot fomentation / cold compresses / electric heating pads. Strong counter irritant ointments.
5. DO NOT walk bearing weight on affected / ulcerated foot or after surgery.
6. CUT the nail regularly with nail clipper & trimmed square by file.
7. DO NOT remove footwear during travel and place your feet on any hot surface and don’t sit cross-legged for a long time.
8. DO NOT cut corns / calluses with a blade or a knife. Home surgery is dangerous.
9. CLEAN the feet twice a day with soap and water. Keep the web space dry and apply softening agent to feet.
10. DO NOT smoke or use tobacco products.
11. The eleventh Commandment for Doctors (if you can help it) DO NOT AMPUTATE.

Rehabilitation

  • Physical therapy exercises and gait training can help prevent future foot ulcers in patients with diabetes. These interventions focus on improving strength, flexibility, balance, and walking mechanics to reduce abnormal pressure on the feet.

CME INDIA Final Points

  • Foot problems are an important cause of morbidity in patients with diabetes mellitus. The lifetime risk of a foot ulcer for patients with type 1 or 2 diabetes may be as high as 34 percent, and the worldwide incidence of diabetic foot ulcers is approximately 18.6 million people per year.
  • Previous foot ulceration, Neuropathy (loss of protective sensation), Foot deformity, vascular disease are the risk factors.
  • Careful foot examination is needed to prevent diabetic foot ulcers.
  • Treatment includes off-loading, debridement, applying medication and controlling blood glucose.

CME INDIA Tail Piece

Other CME INDIA content on Diabetes Foot:

References:

  1. Grigoropoulou P, Eleftheriadou I, Jude EB, et al. Diabetic foot infections: an update in diagnosis and management. Cur. Diab. Rep. 2017 Jan 1;17(1):3.
  2. Pitocco D, Spanu T, Di Leo M, et al. Diabetic foot infections: a comprehensive overview. Eur Rev Med Pharmacol Sci. 2019 Apr 1;23(2):26-37
  3. Zhang P, Lu J, Jing Y, et al. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Ann. Med. 2017 Feb 17;49(2):106-16
  4. Boulton A, Armstrong D, Albert S, et al. Comprehensive foot examination and risk assessment. Endocrine Practice. 2008 Jul 1;14(5):576-83.
  5. Backonja M, Beydoun A, Edwards KR, et al.  symptomatic treatment of painful DPN :a randomized controlled trial. Jama 1998;280(21):1831-6
  6. Clin Ther. 2018 Jun;40(6):828-849. doi: 10.1016/j.clinthera.2018.04.001
  7. Diabetes Metab Res Rev 2011; 27: 629–638
  8. Zilliox LA. Neuropathic Pain. Continuum (Minneap Minn). 2017 Apr;23(2, Selected Topics in Outpatient Neurology):512-32. doi: 10.1212/CON.0000000000000462.
  9. Brian M Schmidt, Keith S Kaye, David G Armstrong, Rodica Pop-Busui, Empirical Antibiotic Therapy in Diabetic Foot Ulcer Infection Increases Hospitalization, Open Forum Infectious Diseases, Volume 10, Issue 10, October 2023, ofad495, https://doi.org/10.1093/ofid/ofad495


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