New national guidelines for the prevention and management of diabetes-related foot disease, its comorbidities and complications reinforce the need for coordinated and multidisciplinary care.
The suite of six guideline documents [link here] making up the evidence-based guidelines include 98 recommendations across prevention, classification, peripheral artery disease (PAD), infection, offloading and wound healing.
They provide a significant and comprehensive update on the previous 2011 guidelines with completely new sections on PAD and infection, and significant changes in the other sections.
Guideline working group co-chair and lead author on a guideline summary in The MJA [link here] Associate Professor Peter Lazzarini told the limbic that diabetes-related foot disease required everyone on board.
“We now have evidence from studies around the world over the last few decades that multidisciplinary teams of doctors, surgeons, allied health and nurses working together and adhering to guidelines can improve outcomes for patients, first and foremost in terms of reducing the incidence of ulcers and in improved healing.”
Associate Professor Lazzarini, conjoint Principal Research Fellow at Metro North Hospital & Health Service and Queensland University of Technology in Brisbane, said the prevention pathway included recommendations on screening for neuropathy and PAD, patient education and self care, footwear and treatments for those at low, moderate and high risk of foot ulceration.
“Basically, there’s recommendations there on how to screen, for any health professional – the GP, endocrinologist, diabetes educator or podiatrist. The main thing we’re trying to do is reduce the likelihood of infection and then hospitalisation, amputation, and unfortunately, mortality.”
He said self-monitoring recommendations like checking foot temperatures daily were stymied by a lack of access to dermal thermometers for patients.
The evidence had shown patients could objectively assess their foot temperatures and that a “hot spot” – more than 2.2 degrees hotter than the same area on the other foot – was a reliable indicator of inflammation.
“It’s a pre-ulcerative lesion that’s likely to lead to an ulcer without good care. So we can detect them and then hopefully prevent them but unfortunately, we don’t have the systems in Australia regulated at this point in time.”
Associate Professor Lazzarini said one of the main areas that could be done better in Australia was the use of offloading devices including casts, moon boots and medical-grade footwear.
“We know from our surveys that originally it was only about 5% of patients and now up to about 30% of patients get them…[whereas] in most patients with diabetic foot ulcers, you should be thinking about offloading.”
“In people with good sensation, if you’ve got high isolated pressure under your foot that will become sore and you’ll offload that naturally by limping or go to see someone about that pain.”
“In people with diabetes-related neuropathy, they’ve lost sensation…and will continue to walk on that, the inflammation will increase and they will get tissue destruction and then ulceration. So we need to remove that pressure or redistribute it with non-removable knee-high offloading devices or removeable knee-high offloading devices.”
He added that use of medical grade footwear in patients with a history of ulcers had been shown to reduce re-ulceration rates by about half.
“So offloading is often overlooked, but in fact it’s probably got the most evidence for healing of any intervention in diabetic foot ulcers.”
He said that the costs of care including for devices and footwear varied considerably depending on where the patient lived.
“So in some primary health care networks or hospital health services, a lot of access will be freely covered by either the state government or usually the state government and supplemented by the federal government.”
“However, that’s not standard across the board unfortunately and in some areas offloading devices in particular or footwear isn’t covered and the patient’s medical insurance will have to pick up the tab.”
“That’s something we’d like introduced as an item either through MBS or National Diabetes Services Scheme (NDSS) because offloading devices and wound dressings in particular fall through the cracks.”
Associate Professor Lazzarini noted that the guidelines included specific advice for care of Aboriginal and Torres Strait Islander Australians who had a three to six fold increased risk of developing diabetes-related foot disease.
Implementation of the new guidelines has been supported by the NDSS with the development of a practical Diabetes and Feet Toolkit [link here] incorporating guideline summaries and schematic diagrams of the recommended care pathways.
Endocrinologist Professor Stephen Twigg, from the University of Sydney, was the other co-chair of the expert guideline working group.