A third of patients with diabetes are at risk of developing foot complications, including ulceration and deformity, even amputation, and need to be closely monitored in the general practice setting, according to Dr Seán Dinneen, consultant endocrinologist, University Hospital, Galway.

Addressing about 100 GPs and nurses at a Diabetes Masterclass in Kilkenny recently, he said that primary healthcare professionals are a pivotal component of the new national model of care for the diabetic foot, which recommends annual foot screening at GP level with referral to podiatrists or a diabetes foot specialist team, where appropriate.

He revealed baseline data from an interim analysis of the west of Ireland Diabetic Foot Study – now in its third year – which investigated the prevalence of foot complications in a group of almost 600 patients with diabetes from 12 general practices. 

Led by Dr Dinneen, the study also offered a snapshot of how many patients developed new complications over a two-year period. 

Study findings

On initial screening, the practice teams found that although most patients had well-controlled diabetes, a quarter (25%) had nerve damage (neuropathy) and lack of sensation; approximately one in 10 (8-10%) had some vascular impairment, and 16% had moderate to severe structural foot deformity. 

“Of these patients, within about 18 months, 16 had developed 19 ulcers – they all came from the high risk group – and there were two amputations. That’s a 2.6% annual ulcer incidence and a 0.35% amputation rate. There was nothing unique about these general practices, this is Ireland and it’s happening, people are losing limbs,” he said.

Diabetic foot disease

Diabetic foot disease is one of the most common, serious, feared and costly complications of diabetes. The principal causative factors are peripheral neuropathy, vascular compromise, ulceration and infection, said Dr Dinneen. These problems are often associated with trauma or foot deformity, and lead to an increased risk of lower limb amputation.

“What our study tells us is that if you have 100 people in your practice with diabetes, about a third are at risk and about 10 of them are in the high-risk group. You need to be aware of this and they need to be aware of the risk to their feet,” he said.

Dr Dinneen also highlighted research from UCC, published in July 2012, which provided the first national estimate of amputation rates in people with diabetes in Ireland. 

Using HIPE (Hospital In-patient Enquiry) data from 2005 to 2009 to identify adults with and without diabetes who underwent amputation, the study found that an individual with diabetes was 22.3 times more likely to undergo a non-traumatic amputation than an individual without diabetes in 2005, and this did not change significantly by 2009.

“On a positive note, in many cases, diabetic foot complications and even amputation can be prevented. We’re getting our act together here in Ireland in terms of diabetes and footcare, and it’s very exciting. We now have a national model of footcare published in 2011, and we’re working on implementing it. 

“From a primary care/general practice standpoint you’re a key part of this national strategy,” he told attendees, “because it recommends that you should screen the feet once a year and assign a risk status of low, moderate or high. If a person is low risk, arrange to screen them again in 12 months; if their risk is moderate, you should ideally engage with podiatrists – that’s a big problem at present because we don’t have enough of them; and if the patient has active foot disease or high risk, you should refer them to a diabetes foot specialist team in a designated centre.”

Low risk

A patient at low risk of diabetic foot disease has:

• Normal foot pulses
• Normal vibration and sensation to 10g monofilament
• No history of foot ulceration
• No significant foot deformity
• No visual impairment. 

In this case, the patient should be managed preventatively through annual screening.

Moderate risk

Patients are at moderate risk if they have any of the following:

• A lack of sensation
• Absence of pulse
• Significant visual problems. 

High risk

High risk patients have:

• Both neuropathy and ischaemia
• Significant deformity
• A history of ulceration or amputation.

If you’ve had previous ulceration your risk of future ulceration is very high.

“So low risk stays with practice nurse; moderate risk patients should be managed by the practice nurse and GP or/plus podiatrist; and high risk patients should be referred without delay to a podiatrist and think about hospital also,” said Dr Dinneen.

Active foot disease

“Then there’s active foot disease – these patients should be managed by a multidisciplinary specialist footcare service. The challenge for us is that we should be seeing these patients between 24 and 48 hours, that’s what the model of care says.”

Extrapolating on findings from the Galway Diabetic Foot Study, Dr Dinneen estimated that a 5% prevalence of diabetes among the 400,000 people living in counties Galway, Mayo and Roscommon, translates into approximately 7,000 diabetes patients in the ‘at risk’ group, and an annual rate of 500 new foot ulcers.

“We’re definitely not seeing anything like that in our clinic, but this is what the foot study would suggest we should be seeing,” he said.

Alarming results from a recent audit of a ‘diabetic foot round’ at University Hospital Galway by Dr David Gallagher, consultant physician in infectious diseases and general internal medicine, found that one in three patients admitted with diabetic foot disease have an amputation. 

There were 35 patient encounters over a short period of time, of which 30 had ulceration for an average duration of seven months. All patients had neuropathy and many had ischemia. 

“There were a total of 12 amputations in this cohort of 35. This is a really stark outcome for these patients; one of their worst fears,” said Dr Dinneen.

Managing the complex foot

There are multiple aspects to the management of the complex diabetic foot, including:

• Mechanical control (“just taking the weight off – it’s not what you put on the wound, it’s what you take off it that’s going to make a difference”); 
• Wound control (dressings, debridement)
• Microbiological (infection) control
• Vascular control (revascularise)
• Metabolic control.

“You need a lot of people to look after the foot well,” he added. “The team would include diabetes doctors and nurses, vascular surgeons and orthopaedic surgeons, community podiatrists, cast technicians, and orthodicists. They do footwear; we need orthodicists as part of the team so when you heal the wound you keep it healed in proper footwear. We don’t yet have one in Galway but we’re in the process of getting one.”

Podiatry is a major aspect of this specialist service but one that is woefully lacking in the Republic of Ireland. “There are more podiatrists working in diabetes care in Northern Ireland with a population of about one million, than there are in the Republic with a population of five million.
I don’t know the order of magnitude but it’s about 10-to-one.

“We need more podiatrists,” he said. “They are the solution to how we convert the ugly duckling – the diabetic foot – into the swan. We have the first and only School of Podiatry in the country in Galway. The first class graduated in November 2012, but a year later, only two of the 12 have part-time employment in the HSE. We absolutely need all 12 of them in hospitals and in the community around the country. The key message is ‘prevention, prevention, prevention’.”