CME / ABIM MOC / CE

New Guidelines for Management of

Diabetic Foot
Authors: News Author: Lisa Nainggolan; CME Author: Charles P. Vega, MD, FAAFPFaculty and Disclosures

CME / ABIM MOC / CE Released: 2/2/2018

Valid for credit through: 2/2/2019

Clinical Context
Diabetic complications of the foot represent one of the most common and
impactful consequences of diabetes. The International Diabetes Federation
(IDF) addresses the prevention and management of complications of the foot
in its current recommendations and sets the stage for these guidelines by
emphasizing the scope of this problem.

Diabetic neuropathy is at the foundation for severe foot complications such as

ulcer and Charcot foot. The prevalence of neuropathy among patients with
diabetes has been estimated to be 16% to 66%. However, less than one-third
of clinicians may be able to recognize the clinical symptoms and signs of
diabetic neuropathy.

Diabetic foot ulcers can occur in up to 25% of patients with diabetes during
their lifetimes, and more than half of these ulcers will become infected.
Approximately 1 in 5 cases of infected diabetic foot ulcers requires
amputation.

The current guidelines from the IDF focus on appropriate risk stratification
for foot complications among patients with diabetes, as well as the prompt
and appropriate management of risk factors as well as foot disease.

Study Synopsis and Perspective

New clinical practice recommendations for the diabetic foot, issued in early
2017 by the IDF, are designed to help all healthcare professionals and, most
specifically, general practitioners and family practice physicians to identify
early those patients who need referral to specialist care.

Introducing these latest guidelines here at the IDF Congress 2017,[1][2] Dr

Edward Jude of Tameside Hospital NHS Foundation Trust, the United
Kingdom, noted that primary care physicians see 80% of diabetic foot cases
worldwide, yet they lack understanding about what they should be assessing
and at what point they should refer a patient.

Prof Johan Wens, a general practitioner (GP) who also works at the
University of Antwerp, Antwerp, Belgium, speaking in the same session,
concurred.[3] "GPs need to be educated that a delay in people with diabetic
foot can lead to loss of a limb, and it's urgent that they are referred."

However, with most GPs having only approximately 10 minutes to see each
patient, on average -- although this depends to some extent on where in the
world they work -- the meeting attendees agreed that this is a huge stumbling
block.

The new 70-page IDF document -- Clinical Practice Recommendations on

the Diabetic Foot 2017: A guide for healthcare professionals[4] -- divides
topics, by increasing severity, into diabetic peripheral neuropathy, peripheral
arterial disease (PAD), ulcers, diabetic foot infection, and Charcot neuro-
osteoarthropathy (Charcot foot).

It is designed with the goal of having GPs intervene at risk category 1 or 2, to

help them identify, assess, and treat patients with diabetic foot earlier in the
"window of presentation" between when neuropathy is diagnosed and before
an ulcer is developing, Dr Jude noted.

The old way of simply "looking for ulcers" means that patients are referred
far too late, delegates heard.

Too Complex for GPs? A Pocket Guide Is Available, Too

However, the chair of the session, Dr William Jeffcoate of Nottingham

University Hospitals Trust, United Kingdom, said he believed that this 70-
page document "is too complicated for primary-care or any other healthcare
professional not working in diabetic-foot disease."

The authors were keen to stress, however, that they have also produced a
pocket chart.[5] This Z-card consists of just 2 pages and can be printed, or a
hard copy can be ordered from the IDF website, Dr Jude explained.

This short document enables physicians to put patients into 1 of 4 risk

categories based on the results of assessment and then provides advice on
future decisions depending on the risk category assigned.

Nevertheless, Prof Wens observed that much work remains to be done.

Looking for relevant clinical trials, he found that little research is available
regarding the feasibility and implementation of diabetic foot guidelines in
primary care, although at least 10 such guidelines exist around the world,
including guidelines from the American Diabetes Association and these latest
from the IDF.

In addition, sections are still missing from all of these guidelines, he said,
including training for healthcare professionals on the diabetic foot.

"It's very confusing for primary-care practitioners -- when to do this and how
to do this," he observed.

The 3-Minute Diabetic Foot Examination: Look at, Touch the Feet,
Ask Questions

Podiatrist Lawrence B. Harkless, DPM, of the Western University of Health

Sciences, Pomona, California, concurred with the other speakers that primary
care providers "are very busy" and the foot "is way down on their list."[6]

Having trained family medicine residents on podiatric medicine, he offers

some simple tips for physicians and he cited the "3-minute exam," which can
help raise a red flag for any patients at risk for foot ulcer; details of this were
published in 2014 in the Journal of Family Practice.[7]

First, physicians have to take a quick but thorough medical history, and they
have to actually look at and touch the foot, he stressed.
"Just by observing the skin -- if you see discolored skin, mycotic nails,
hyperpigmentation, bleeding under the toenail, maceration, and calluses,
which precede ulcers," these are all warning signs, he explained.

Second, it is also vital to palpate, touching the foot and ankle, looking at
capillary refill time, temperature changes, pedal pulse, etc.

Looking at and feeling the foot also give clues for any signs of vascular
disease, he added. These signs include an absence of hair, atrophy of the skin
or subcutaneous tissue (the "baked-potato" look), edema, pallor, and cold
temperature.

"Every complication in diabetes is related to blood flow," Dr Harkless told

Medscape Medical News. "So if you do an assessment of the vasculature, and
if they have any signs or symptoms in terms of the skin, discoloration, nails,
callus -- because ulcers are preceded by callus -- that's enough to send to the
specialist."

"Also, do they have neuropathy?" he added. That is, on neurologic

examination, is the patient responsive to the Ipswich Touch test or to a
monofilament test?

In addition, is there any deformity and/or limited joint mobility, and if so,
how long has it been present? Is the midfoot hot, red, or swollen? Is there any
malalignment on gait analysis?

Teach Your Patients Foot Care

Dr Harkless also recommends that physicians teach their patients daily foot
care. It is important to make certain that the patient or a family member can
visually examine both feet soles and between the toes, and that the patient
keeps the feet dry and reports any new lesions, discolorations, or swelling to
a healthcare professional.

Patients also need to be advised about the risk associated with walking
barefoot, even indoors, and it is vital that they have appropriate footwear and
not shoes that are too small and/or rub against the foot.
 Finally, patients need to comprehend that general health is important, and this
includes the role of smoking cessation. In addition, it is vital that physicians
explain to patients the importance of keeping blood glucose levels under
control and how this, in turn, helps to prevent neuropathy or prevent progress
if already present, including protection of the feet, Dr Harkless concluded.

IDF Congress 2017: International Diabetes Federation Congress

2017. December 4-8, 2017; Abu Dhabi, United Arab Emirates.

Guideline Highlights
 All patients with diabetes should undergo routine screening with a
monofilament to detect diabetic neuropathy. Patients may also require testing
for vibratory and temperature sensation.
 In addition, clinicians should test patients with diabetes for power at the ankle
and first toe, as well as have the patient splay the toes against resistance.
 Patients who have normal results on examination may be reexamined in 1
year. Patients who experience a loss of sensation only should be rechecked
within 6 months and should receive soft-molded insoles for their shoes.
 Patients who experience a loss of sensation plus evidence of (1) PAD, (2)
structural foot deformities, or (3) onychomycosis should be reevaluated
within 3 months. They should be treated with custom insoles to offload
pressure on at-risk areas of the foot.
 The highest-risk category is defined as a history of ulceration, amputation, or
neuropathic fracture. These patients require routine specialist follow-up and
reevaluation at least once per month.
 Onychomycosis can affect more than one-third of patients with diabetes, and
it increases the risks for ulceration and gangrene by a factor of 3. Patients
with diabetes should be evaluated for the presence of onychomycosis and
should be considered for treatment as well.
 In 1 study, more than half of patients with diabetes had no palpable pedal
pulses; this finding increases the risk for ulceration by nearly a factor of 5.
 Dependent rubor (a dusky red color when the lower leg is in a dependent
position) is a sign of PAD.
 The ankle-brachial index (ABI) is commonly used to identify PAD, but it
may be limited among patients with diabetes because it does not identify
PAD at an early stage, and arterial calcinosis can cause a false-negative
result. That said, an ABI of less than 0.90 should be considered abnormal and
requires further care.
 The most important component in the treatment of diabetic foot ulcers is
offloading pressure on the affected area. The patient should not be weight
bearing on the affected extremity. Foam padding or wedged shoes are not as
effective.
 Diabetic foot ulcers should be debrided and require a moist environment for
healing. Negative pressure wound therapy can accelerate the healing of
ulcers.
 Wounds that do not improve by at least 50% in diameter within 4 weeks
should be referred for more advanced techniques in wound care.
 Wound cultures should be collected when there is suspicion of a diabetic foot
ulcer infection, and blood cultures are only necessary if there are systemic
signs of infection.
 Plain radiographs should be performed in cases of diabetic foot infection.
Magnetic resonance imaging is the test of choice if there is questionable
osteomyelitis, although a probe through the ulcer to bone is highly suggestive
of osteomyelitis in a high-risk patient.
 Antimicrobial therapy is only necessary if a diabetic foot ulcer appears
infected. Mild to moderate infections should require 1 to 2 weeks of
treatment. Three weeks is usually sufficient for more severe infections, and
antimicrobials can be stopped when symptoms and signs of infection have
resolved.
 An elevated temperature of one foot vs the other is the best sign that the
patient is at risk for bony breakdown associated with a Charcot foot.
 Approximately 9% of patients with diabetic neuropathy develop a Charcot
foot. Charcot changes usually occur in the midfoot, followed by the hind foot
and ankle.
 Offloading the incipient Charcot foot with a total-contact cast is the most
recommended therapy. The usual course is 4 to 6 months, and the cast may
be removed when the temperature normalizes in comparing the 2 feet.
 Charcot joint of the midfoot is the most amenable to therapy.
Clinical Implications
 Current guidelines from the IDF recommend that patients with diabetes and a
loss of pedal sensation should receive soft-molded insoles and be reevaluated
in 6 months. If these patients also have other risk factors for a diabetic foot
ulcer, they should be treated with custom insoles and reevaluated in 3
months.
 These guidelines also recommend offloading of weight and pressure as the
most critical treatments for diabetic foot ulcer and Charcot foot. Wound
cultures and antibiotic treatment of diabetic foot ulcers are only necessary in
cases of suspected infection. A total-contact cast is recommended to treat
early Charcot changes.
 Implications for the healthcare team: Good care of the feet among patients
with diabetes requires a team of providers and empowerment of the patient.
The current IDF recommendations will not be effective without a clear
delegation of duties and strong team communication.