Diabetic foot primary prevention: Difference between revisions
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The primary prevention of diabetic foot ulcer includes control of blood sugar levels , pressure offloading, frequent physical examinations, good foot hygiene, [[diabetic sock]]s and shoes, and by avoiding injury. | The primary prevention of diabetic foot ulcer includes control of blood sugar levels , pressure offloading, frequent physical examinations, good foot hygiene, [[diabetic sock]]s and shoes, and by avoiding injury. | ||
==Primary Prevention== | ==Primary Prevention== | ||
[[Foot]] [[ulcers]] can be prevented by is by frequent [[physical examinations]], good [[foot]] [[hygiene]], [[diabetic sock]]s and shoes, and by avoiding injury.<ref name="pmid28614678">{{cite journal| author=Armstrong DG, Boulton AJM, Bus SA| title=Diabetic Foot Ulcers and Their Recurrence. | journal=N Engl J Med | year= 2017 | volume= 376 | issue= 24 | pages= 2367-2375 | pmid=28614678 | doi=10.1056/NEJMra1615439 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28614678 }} </ref> | [[Foot]] [[ulcers]] can be prevented by is by frequent [[physical examinations]], good [[foot]] [[hygiene]], [[diabetic sock]]s and shoes, and by avoiding injury.<ref name="pmid28614678">{{cite journal| author=Armstrong DG, Boulton AJM, Bus SA| title=Diabetic Foot Ulcers and Their Recurrence. | journal=N Engl J Med | year= 2017 | volume= 376 | issue= 24 | pages= 2367-2375 | pmid=28614678 | doi=10.1056/NEJMra1615439 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28614678 }} </ref><ref name="pmid9834731">{{cite journal| author=Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S | display-authors=etal| title=1998 clinical practice guidelines for the management of diabetes in Canada. Canadian Diabetes Association. | journal=CMAJ | year= 1998 | volume= 159 Suppl 8 | issue= | pages= S1-29 | pmid=9834731 | doi= | pmc=1255890 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9834731 }} </ref><ref name="pmid9839111">{{cite journal| author=Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM| title=Preventive foot care in people with diabetes. | journal=Diabetes Care | year= 1998 | volume= 21 | issue= 12 | pages= 2161-77 | pmid=9839111 | doi=10.2337/diacare.21.12.2161 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9839111 }} </ref> | ||
*Control of [[blood sugar]] levels | *Control of [[blood sugar]] levels | ||
*Pressure off loading | *Pressure off loading | ||
| Line 22: | Line 22: | ||
====Clinical Trials==== | ====Clinical Trials==== | ||
''Clinical Evidence'' reviewed the topic and concluded "Individuals with significant foot deformities should be considered for referral and assessment for customized shoes that can accommodate the altered foot anatomy. In the absence of significant deformities, high quality well fitting non-prescription | *''Clinical Evidence'' reviewed the topic and concluded "Individuals with significant [[foot]] deformities should be considered for referral and assessment for customized shoes that can accommodate the altered [[foot]] [[anatomy]]. In the absence of significant deformities, high quality well fitting non-prescription [[foot]]wear seems to be a reasonable option".<ref name="pmid16620415">{{cite journal |author=Hunt D |title=Foot ulcers and amputations in diabetes |journal=Clin Evid |volume= |issue= |pages=455-62 |year= |pmid=16620415 |url = http://clinicalevidence.com/ceweb/conditions/dia/0602/0602_I5.jsp | based on September 2005 search}}</ref> | ||
*[[National Institute for Health and Clinical Excellence]] has reviewed the topic and concluded that for [[patients]] who are at "high risk of [[foot]] [[ulcers]] ([[neuropathy]] or absent [[pulse|pulses]] plus deformity or [[skin]] changes or previous [[ulcer]]", "specialist [[foot]]wear and insoles" should be provided. <ref name="webNICE">{{cite web | |||
[[National Institute for Health and Clinical Excellence]] has reviewed the topic and concluded that for patients at "high risk of foot ulcers (neuropathy or absent pulses plus deformity or skin changes or previous ulcer" | |||
| title = Scope: Management of type 2 diabetes: prevention and management of foot problems (update) | | title = Scope: Management of type 2 diabetes: prevention and management of foot problems (update) | ||
| work = Clinical Guidelines and Evidence Review for Type 2 Diabetes: Prevention and Management of Foot Problems | | work = Clinical Guidelines and Evidence Review for Type 2 Diabetes: Prevention and Management of Foot Problems | ||
| Line 33: | Line 32: | ||
| accessdate = 2007-12-04 | | accessdate = 2007-12-04 | ||
}}</ref> | }}</ref> | ||
*A [[meta-analysis]] by the [[Cochrane Collaboration]] concluded that "there is very limited evidence of the effectiveness of therapeutic shoes". <ref name="pmid10908550">{{cite journal |author=Spencer S |title=Pressure relieving interventions for preventing and treating diabetic foot ulcers |journal=Cochrane Database Syst Rev |volume= |issue= |pages=CD002302 |year= |pmid=10908550 | doi=10.1002/14651858.CD002302}}</ref> However, the meta-analysis was published before the major trial that is in the table below. | |||
A [[meta-analysis]] by the [[Cochrane Collaboration]] concluded that "there is very limited evidence of the effectiveness of therapeutic shoes". <ref name="pmid10908550">{{cite journal |author=Spencer S |title=Pressure relieving interventions for preventing and treating diabetic foot ulcers |journal=Cochrane Database Syst Rev |volume= |issue= |pages=CD002302 |year= |pmid=10908550 | doi=10.1002/14651858.CD002302}}</ref> However, the meta-analysis was published before the major trial that is in the table below. | *A small and non-randomized trial showed the benefits of custom [[foot]]wear in [[patients]] with a prior [[foot]][[ulcer|ulceration]], with a [[number needed to treat]] of 4 [[patients]].<ref name=pmid8721941">{{cite journal |author=Uccioli L, Faglia E, Monticone G, Favales F, Durola L, Aldeghi A, Quarantiello A, Calia P, Menzinger G |title=Manufactured shoes in the prevention of diabetic foot ulcers |journal=Diabetes Care |volume=18 |issue=10 |pages=1376-8 |year=1995 |pmid=8721941}}</ref> | ||
*A major [[randomized controlled trial]] of specialized [[foot]]wear showed no benefit for [[patients]] with a prior [[foot]] [[ulcer|ulceration]] (see table below).<ref name="pmid12020336">{{cite journal| author=Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C et al.| title=Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. | journal=JAMA | year= 2002 | volume= 287 | issue= 19 | pages= 2552-8 | pmid=12020336 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12020336 }} </ref> | |||
{| class="wikitable" | {| class="wikitable" | ||
|+ Randomized controlled trials of interventions to prevent complications of diabetic foot.<ref name="pmid12020336">{{cite journal| author=Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C et al.| title=Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. | journal=JAMA | year= 2002 | volume= 287 | issue= 19 | pages= 2552-8 | pmid=12020336 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12020336 }} </ref> <ref name="pmid8498761">{{cite journal| author=Litzelman DK, Slemenda CW, Langefeld CD, Hays LM, Welch MA, Bild DE et al.| title=Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial. | journal=Ann Intern Med | year= 1993 | volume= 119 | issue= 1 | pages= 36-41 | pmid=8498761 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8498761 }} </ref> <ref name="pmid9472868">{{cite journal| author=McCabe CJ, Stevenson RC, Dolan AM| title=Evaluation of a diabetic foot screening and protection programme. | journal=Diabet Med | year= 1998 | volume= 15 | issue= 1 | pages= 80-4 | pmid=9472868 | doi=10.1002/(SICI)1096-9136(199801)15:1<80::AID-DIA517>3.0.CO;2-K | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9472868 }} </ref> <ref name="pmid18758747">{{cite journal| author=Lincoln NB, Radford KA, Game FL, Jeffcoate WJ| title=Education for secondary prevention of foot ulcers in people with diabetes: a randomised controlled trial. | journal=Diabetologia | year= 2008 | volume= 51 | issue= 11 | pages= 1954-61 | pmid=18758747 | doi=10.1007/s00125-008-1110-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18758747 }} </ref> | |+ Randomized controlled trials of interventions to prevent complications of diabetic foot.<ref name="pmid12020336">{{cite journal| author=Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C et al.| title=Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. | journal=JAMA | year= 2002 | volume= 287 | issue= 19 | pages= 2552-8 | pmid=12020336 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12020336 }} </ref> <ref name="pmid8498761">{{cite journal| author=Litzelman DK, Slemenda CW, Langefeld CD, Hays LM, Welch MA, Bild DE et al.| title=Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial. | journal=Ann Intern Med | year= 1993 | volume= 119 | issue= 1 | pages= 36-41 | pmid=8498761 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8498761 }} </ref> <ref name="pmid9472868">{{cite journal| author=McCabe CJ, Stevenson RC, Dolan AM| title=Evaluation of a diabetic foot screening and protection programme. | journal=Diabet Med | year= 1998 | volume= 15 | issue= 1 | pages= 80-4 | pmid=9472868 | doi=10.1002/(SICI)1096-9136(199801)15:1<80::AID-DIA517>3.0.CO;2-K | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9472868 }} </ref> <ref name="pmid18758747">{{cite journal| author=Lincoln NB, Radford KA, Game FL, Jeffcoate WJ| title=Education for secondary prevention of foot ulcers in people with diabetes: a randomised controlled trial. | journal=Diabetologia | year= 2008 | volume= 51 | issue= 11 | pages= 1954-61 | pmid=18758747 | doi=10.1007/s00125-008-1110-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18758747 }} </ref> | ||
| Line 44: | Line 41: | ||
! Intervention!!Control | ! Intervention!!Control | ||
|- | |- | ||
| Litzelman<ref name="pmid8498761"/><br/>1993|| 395 patients<br/>• General medicine practice|| Patient and provider education||Usual care||• Any foot lesion<br/> • Serious foot lesions at one year|| Not reported||• 11%<br/>• 2.9%||<br/>• Insignificant <br/>• Significant reduction | | Litzelman<ref name="pmid8498761"/><br/>1993|| 395 patients<br/>• General medicine practice|| [[Patient]] and provider education||Usual care||• Any [[foot]] lesion<br/> • Serious [[foot]] lesions at one year|| Not reported||• 11%<br/>• 2.9%||<br/>• Insignificant <br/>• Significant reduction | ||
|- | |- | ||
| Lincoln<ref name="pmid18758747"/><br/>2008|| 172 patients<br/>• Prior ulceration<br/>• Specialist clinic|| Targeted, one-to-one education ||Usual care||Re-ulceration at<br/>• 1 year<br/>2 years|| • 30%<br/>• 41%||• 20%<br/>• 41%||• Insignificant<br/>• Insignificant | | Lincoln<ref name="pmid18758747"/><br/>2008|| 172 patients<br/>• Prior ulceration<br/>• Specialist clinic|| Targeted, one-to-one education ||Usual care||Re-ulceration at<br/>• 1 year<br/>2 years|| • 30%<br/>• 41%||• 20%<br/>• 41%||• Insignificant<br/>• Insignificant | ||
|- | |- | ||
| McCabe<ref name="pmid9472868"/><br/>1998|| 2002 patients<br/>• High-risk<br/>• General diabetic clinic|| Screening and referral to foot-care clinic if they | | McCabe<ref name="pmid9472868"/><br/>1998|| 2002 patients<br/>• High-risk<br/>• General diabetic clinic|| [[Screening (medicine)|Screening]] and referral to [[foot]]-care clinic if they had prior [[ulcer]], low [[ABI|ankle–brachial index]] (<0.75), or [[foot]] deformities||Usual care||• [[ulcer|Ulceration]] within 2 years<br/>• [[Amputation]] rates|| • 2%<br/>• 0.1%|| 4%<br/>1.2%||• Insignificant<br/>• Significant | ||
|- | |- | ||
| Reiber<ref name="pmid12020336"/><br/>2002|| 400 patients<br/>• Prior ulceration<br/>• Excluded severe deformity||Therapeutic shoes||Usual | | Reiber<ref name="pmid12020336"/><br/>2002|| 400 patients<br/>• Prior [[ulcer|ulceration]]<br/>• Excluded severe deformity||Therapeutic shoes||Usual [[foot]]wear|| Re-ulceration || 15%|| 17%|| Insignificant difference | ||
|} | |} | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vishnu Vardhan Serla M.B.B.S. [2], Usama Talib, BSc, MD [3]
Overview
The primary prevention of diabetic foot ulcer includes control of blood sugar levels , pressure offloading, frequent physical examinations, good foot hygiene, diabetic socks and shoes, and by avoiding injury.
Primary Prevention
Foot ulcers can be prevented by is by frequent physical examinations, good foot hygiene, diabetic socks and shoes, and by avoiding injury.[1][2][3]
- Control of blood sugar levels
- Pressure off loading
- Regular examinations
- Studies recommend annual screening for every diabetic patient older than 15 years old by the physician and more frequent for patients who are at risk (such as neuropathy).
- Daily foot examination should be done by the patient him/herself.
- Prevention of infection
- Foot-care education:
- Proper foodwear
Clinical Trials
- Clinical Evidence reviewed the topic and concluded "Individuals with significant foot deformities should be considered for referral and assessment for customized shoes that can accommodate the altered foot anatomy. In the absence of significant deformities, high quality well fitting non-prescription footwear seems to be a reasonable option".[5]
- National Institute for Health and Clinical Excellence has reviewed the topic and concluded that for patients who are at "high risk of foot ulcers (neuropathy or absent pulses plus deformity or skin changes or previous ulcer", "specialist footwear and insoles" should be provided. [6]
- A meta-analysis by the Cochrane Collaboration concluded that "there is very limited evidence of the effectiveness of therapeutic shoes". [7] However, the meta-analysis was published before the major trial that is in the table below.
- A small and non-randomized trial showed the benefits of custom footwear in patients with a prior footulceration, with a number needed to treat of 4 patients.[8]
- A major randomized controlled trial of specialized footwear showed no benefit for patients with a prior foot ulceration (see table below).[9]
| Trial | Patients | Intervention | Comparison | Outcome | Results | Comment | |
|---|---|---|---|---|---|---|---|
| Intervention | Control | ||||||
| Litzelman[4] 1993 |
395 patients • General medicine practice |
Patient and provider education | Usual care | • Any foot lesion • Serious foot lesions at one year |
Not reported | • 11% • 2.9% |
• Insignificant • Significant reduction |
| Lincoln[11] 2008 |
172 patients • Prior ulceration • Specialist clinic |
Targeted, one-to-one education | Usual care | Re-ulceration at • 1 year 2 years |
• 30% • 41% |
• 20% • 41% |
• Insignificant • Insignificant |
| McCabe[10] 1998 |
2002 patients • High-risk • General diabetic clinic |
Screening and referral to foot-care clinic if they had prior ulcer, low ankle–brachial index (<0.75), or foot deformities | Usual care | • Ulceration within 2 years • Amputation rates |
• 2% • 0.1% |
4% 1.2% |
• Insignificant • Significant |
| Reiber[9] 2002 |
400 patients • Prior ulceration • Excluded severe deformity |
Therapeutic shoes | Usual footwear | Re-ulceration | 15% | 17% | Insignificant difference |
Video: Diabetic Foot Care
{{#ev:youtube|DASvmFJeYX8}}
References
- ↑ Armstrong DG, Boulton AJM, Bus SA (2017). "Diabetic Foot Ulcers and Their Recurrence". N Engl J Med. 376 (24): 2367–2375. doi:10.1056/NEJMra1615439. PMID 28614678.
- ↑ Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S; et al. (1998). "1998 clinical practice guidelines for the management of diabetes in Canada. Canadian Diabetes Association". CMAJ. 159 Suppl 8: S1–29. PMC 1255890. PMID 9834731.
- ↑ Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM (1998). "Preventive foot care in people with diabetes". Diabetes Care. 21 (12): 2161–77. doi:10.2337/diacare.21.12.2161. PMID 9839111.
- ↑ 4.0 4.1 4.2 Litzelman D, Slemenda C, Langefeld C, Hays L, Welch M, Bild D, Ford E, Vinicor F (1993). "Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial". Ann Intern Med. 119 (1): 36–41. PMID 8498761.
- ↑ Hunt D. "Foot ulcers and amputations in diabetes". Clin Evid: 455–62. PMID 16620415. Text " based on September 2005 search" ignored (help)
- ↑ "Scope: Management of type 2 diabetes: prevention and management of foot problems (update)" (PDF). Clinical Guidelines and Evidence Review for Type 2 Diabetes: Prevention and Management of Foot Problems. National Institute for Health and Clinical Excellence. 20 February 2003. Retrieved 2007-12-04.
- ↑ Spencer S. "Pressure relieving interventions for preventing and treating diabetic foot ulcers". Cochrane Database Syst Rev: CD002302. doi:10.1002/14651858.CD002302. PMID 10908550.
- ↑ Uccioli L, Faglia E, Monticone G, Favales F, Durola L, Aldeghi A, Quarantiello A, Calia P, Menzinger G (1995). "Manufactured shoes in the prevention of diabetic foot ulcers". Diabetes Care. 18 (10): 1376–8. PMID 8721941.
- ↑ 9.0 9.1 9.2 Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C; et al. (2002). "Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial". JAMA. 287 (19): 2552–8. PMID 12020336.
- ↑ 10.0 10.1 McCabe CJ, Stevenson RC, Dolan AM (1998). "Evaluation of a diabetic foot screening and protection programme". Diabet Med. 15 (1): 80–4. doi:10.1002/(SICI)1096-9136(199801)15:1<80::AID-DIA517>3.0.CO;2-K. PMID 9472868.
- ↑ 11.0 11.1 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ (2008). "Education for secondary prevention of foot ulcers in people with diabetes: a randomised controlled trial". Diabetologia. 51 (11): 1954–61. doi:10.1007/s00125-008-1110-0. PMID 18758747.