Current advice to pharmacists on diabetic foot and its management

According to Diabetic Foot Australia (DFA), in Australia, approximately 380,000 people are at high risk of developing diabetic foot disease.

“We know from our latest data that each day four people die, 12 undergo an amputation and 1,000 people are in hospital because of diabetic foot disease,” said a DFA expert.

“Diabetic foot disease is a complication of diabetes. A common complication of diabetes is damage to the nerves in the feet. The damaged nerve function is called peripheral neuropathy, and about half of all people with diabetes will develop this nerve damage.”

Neuropathy results in either pain, tingling, weakness and most typically, reduced sensation in the feet. A loss of sensation in the feet often leads to an abnormal walking pattern, causing increased pressure in certain areas of the foot. The development of new calluses can be an indication of abnormal pressure being applied and continuing to walk unnaturally on an ‘insensitive foot’ increases the likelihood of ulcers forming, and reduces the ability of the body to heal an existing ulcer.

Because of the loss of sensation in the foot, a person with diabetes would be less likely to realise they’ve injured their foot, as they may not have the ability to feel pain. This means they are less likely to notice and treat an injury, allowing it to progress to a more serious, advanced stage such as a foot ulcer or infection, the DFA expert said.

Unfortunately, in addition to peripheral neuropathy, people with diabetes also have a much higher risk of developing peripheral arterial disease in the arteries in the lower leg that can result in poor perfusion to the foot. This creates a ‘double whammy’ situation if people have also developed peripheral neuropathy, as these people have an inability to detect pain or damage to their feet due to their neuropathy.

In addition, the inability to heal this damage due to their peripheral arterial disease means they can end up with foot ulcers and infections without frequent multidisciplinary, evidence-based intervention.  According to recent Australian research, the introduction of multidisciplinary foot teams has reduced diabetic foot disease hospitalisation and amputation rates by around 50 per cent.

Multidisciplinary care

Diabetic Foot Australia says diabetic foot disease (ulcers, infections or ischaemia) care should take place in multidisciplinary foot teams.

“The cornerstone of diabetic foot care is multidisciplinary treatment, as no single health professional can deal with the complex medical problem on their own. Multidisciplinary care requires active involvement from various healthcare professionals, and good inter-professional communication. When caring for a person with diabetic foot disease, always ensure that the whole team is involved, with the person themselves being of course the most important team member,” a DFA expert said.

Pharmacists, like all health professionals, are strongly encouraged to advise people with diabetic foot disease, in conjunction with their GPs, to seek the treatment by their local multidisciplinary foot team.

Pharmacists also play a particularly important role in relation to medication adherence for patients with diabetic foot disease, especially around anti-diabetic agents and any prescribed antibiotics for diagnosed foot infections, said Diabetic Foot Australia.

Furthermore, it is also important for pharmacists and other health professionals to advise all people with diabetes – without a history of foot disease – to have their feet assessed annually by a trained health professional to detect diabetic foot disease or any risk factors for developing diabetic foot disease (such as peripheral neuropathy and peripheral arterial disease).

The latest findings on the prevention and management of foot problems in diabetes can be found in the 2015 Guidance published by the International Working Group on the Diabetic Foot. For Australia, one should also read the 2011 NHMRC guidelines. Diabetic Foot Australia has summarised these documents in a free to download paper. This short summary can be used by health professionals to gain a quick understanding of the latest in the management of the diabetic foot. Diabetic Food Australia said that pharmacists might be particularly interested in the sections, which summarise the evidence on prevention of foot ulcers and management of diabetic foot disease (especially foot infection).

Role of the pharmacist

Preventing the development of diabetes and its complications, including neuropathy and peripheral arterial disease, is of paramount importance. Pharmacists can assist this process by encouraging: high-risk individuals to be screened for diabetes; individuals with diabetes to regularly monitor and control their diabetes and; compliance with anti-diabetic, anti-lipid and anti-hypertensives so as to prevent diabetes related complications. Should an individual develop a diabetic foot infection, then compliance with antibiotics and strategies to reduce antibiotic related side effects is important, Diabetic Foot Australia experts said.

Various specific wound care pharmaceuticals to treat diabetic foot disease have been developed and investigated over the past 10 to 20 years. While evidence suggests these may have some minor additional benefit in wound healing, multidisciplinary foot and wound care by a team of qualified professionals is the biggest contributor to good outcomes.

Pharmacists could bridge the gap to multidisciplinary diabetic foot teams by reaching out to these teams as soon as they are aware of a patient with diabetic foot disease, and investigate ways to engage as close as possible with these teams, or even become a team member.

Pharmacists should also be very cautious of recommending the use of over-the-counter ‘corn pads’ and ‘callus cures’ in patients at risk of developing diabetic foot disease. These over-the-counter products can cause significant foot ulcers in patients with peripheral neuropathy and peripheral arterial disease. According to DFA, for patients with diabetes and corns or calluses it would be wiser to refer them to a health professional for a diabetic foot assessment to determine their risk of developing foot disease before recommending any over-the-counter product in this regard.