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Concise guide: Dealing with diabetic foot problems

NICE recently updated its guideline on diabetic foot problems and a number of the recommendations can be supported by community pharmacy.

Diabetes is one of the commonest chronic diseases in the UK and its prevalence is increasing. That is the stark statement that opens the new NICE guideline on diabetic foot problems.1 In 2013, it says, there were almost 2.9 million people in the UK diagnosed with diabetes but by 2025 that figure is expected to rise to more than 5 million.

Foot complications are common in people with diabetes. Around 10 per cent of people with the disease will have a diabetic foot ulcer at some point in their lives. NICE defines this as “a localised injury to the skin and/or underlying tissue, below the ankle, in a person with diabetes”.

Increased risk

The risk of foot problems in people with diabetes is increased, the guidelines say, largely because of either diabetic neuropathy (nerve damage or degeneration because of the high blood sugar levels) or peripheral arterial disease (poor blood supply due to diseased large and mediumsized blood vessels in the legs), or both:

  • Nerve damage can mean that injuries like cuts go unnoticed and can develop into an open sore on the foot – a diabetic foot ulcer. If the ulcer becomes infected, there is a risk that the foot tissue may die and the foot itself might have to be amputated
  • Peripheral arterial disease affects one in three people with diabetes over the age of 50 and can also increase the risk of heart attack and stroke.

NICE goes on to point out that diabetes is also the commonest cause of non-traumatic limb amputation, with diabetic foot ulcers preceding more than 80 per cent of amputations in people with diabetes.

After a first amputation, people with diabetes are twice as likely to have a subsequent one as people without the disease. According to Diabetes UK, more than 135 people with diabetes have a leg, foot or toe amputated each week.

It should be noted that, although people of South Asian, African and African-Caribbean family origin are more at risk of diabetes, there is no evidence that the prevalence of diabetic foot ulceration and amputation is higher in these sub-groups than in the general population of people with diabetes in the UK.

 

NICE advice on diabetic foot problems

Examples of limb-threatening and life-threatening diabetic foot include:

  • Ulceration with fever or any signs of sepsis
  • Ulceration with limb ischaemia
  • Clinical concerns that there is a deep-seated soft tissue or bone infection (with or without ulceration)
  • Gangrene (with or without ulceration).

 

Clear information

“Diabetic foot problems are serious and if not managed appropriately can lead to minor or major amputations and even death,” says Rachel Berrington, diabetes specialist nurse and NICE guideline developer. “Mortality rates after diabetic foot ulceration and amputations are high, with up to 70 per cent of people dying within five years of having an amputation and around 50 per cent dying within five years of developing a diabetic foot ulcer.”

This high mortality rate is believed to be associated with cardiovascular disease and emphasises the importance of good diabetic and cardiovascular risk management.  This guideline sets the standard for managing diabetic foot problems for all people with diabetes, including children and young people, in all NHS settings, says Berrington.

“For example, the guideline identifies people who need immediate attention from the multidisciplinary foot care service or acute services. The guideline also highlights the need for clear information and education for all people with diabetes about diabetic foot problems, so they know what care to expect, the importance of foot care and who to contact in an emergency.”

Foot problems in people with diabetes can quickly become devastating for the person concerned – and extremely costly for the NHS. A report published in 2012 estimated that around £650 million (£1 for every £150 the NHS spends) goes on foot ulcers or amputations each year.

Table 1: Footcare checklist2

Bridging the gap

With foot care screening programmes across the UK described by NICE as variable, the guidance covers the prevention and management of foot problems in children, young people and adults with diabetes, with the aim of reducing variation in practice. It recommends that commissioners and service providers ensure there is a foot protection service for preventing, treating and managing diabetic foot problems in the community.

Community pharmacy is ideally placed to supply relevant information and signpost people to the help they need.

NICE advises that patients with diabetic foot problems and/or their family members or carers should be provided with information and clear explanations about the risk of developing a diabetic foot problem when diabetes is diagnosed, during assessments, and if problems arise.

In April, Diabetes UK estimated that more than 400,000 people with diabetes in England were not having an annual foot check, despite the recommendation by NICE. The charity also claimed that in many cases where people do get foot checks, they are not thorough enough, with some people not even being asked to remove their shoes or socks.3

Its Putting Feet First campaign4 encourages all healthcare professionals to:

  • Understand and discuss the risk of diabetic foot disease with people with diabetes
  • Give people with diabetes its leaflet about the importance of their annual foot check
  • Refer quickly to specialists where necessary
  • Participate in diabetes networks to influence the delivery of integrated care in their local area.

The community pharmacy team can help by:

  • Identifying patients with diabetes who come into the pharmacy with a prescription for diabetes-related medicines
  • Asking whether the person with diabetes has had their feet checked in the previous year. If the answer is no, then reinforce the need for a regular check and direct them to the Diabetes UK Putting Feet First campaign materials
  • Stressing how important it is to look after the feet and ask about the patient’s daily routine
  • Reinforcing the need to speak to their doctor/nurse/podiatrist immediately if they notice redness, swelling or a change in shape (consider the checklist in Table 2).

It is also important to make sure people with diabetic foot problems know to:

  • Check their feet every day, looking for any signs of redness, pain, build-up of hard skin or changes in the shape of the feet (see Table 2 for tips on how to spot foot problems)
  • Be aware of any loss of feeling in their feet
  • Look after their toenails
  • Use moisturising cream every day and wear well-fitting shoes that protect and support their feet
  • Never use corn removing plasters or blades to remove hard skin
  • Make sure their shoes fit well and offer protection and support to the feet
  • Always examine the inside of shoes for sharp objects or stones before putting them on and replace ruffled inner-sole linings
  • Avoid socks, stockings or tights that might restrict the circulation
  • Know whom to call at the first sign of any new foot problem and not leave it until their annual foot review.

 

Foot ulcer assessment 

The risk of developing a diabetic foot ulcer is assessed as:

  • Low risk: no risk factors present
  • Moderate risk: one risk factor present
  • High risk: previous ulceration or amputation, on renal replacement therapy, or more than one risk factor present
  • Active diabetic foot problem: ulceration, spreading infection, critical ischaemia, gangrene, suspicion of an acute Charcot arthropathy, or an unexplained hot, red, swollen foot with or without pain.

 

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