Guidelines for Diabetic Foot Management

New evidence-based clinical-practiceguidelines on diabetic foot management cover five areas: ulcer prevention, off-loading, osteomyelitis diagnosis, wound care, and peripheral arterial disease. This is the first diabetic foot guideline developed by a multidisciplinary panel, which conducted separate systematic literature reviews for each of the five topics.

The document, sponsored jointly by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine, was published as a supplement to the February issue of the Journal of Vascular Surgery by Anil Hingorani, MD, of New York University Lutheran Medical Center, Brooklyn, and colleagues.

Asked to comment, endocrinologist and diabetic foot expert Jan S Ulbrecht, MD, of Pennsylvania State University, State College, told Medscape Medical News, "I think it's a hugely ambitious and comprehensive document, from a very distinguished group of authors." Dr. Ulbrecht added that although he takes issue with a few specific points, "There can be no doubt that if all care followed these guidelines, diabetic foot disease would be markedly diminished."

Five Recommendations: Examine Feet at Every Visit

The panel issued five recommendations for the care of the diabetic foot.

#1. For prevention of foot ulceration, the panel advises adequate glycemic control, periodic foot inspection, and patient and family education. For high-risk patients, including those with significant neuropathy, foot deformities, or previous amputation, custom therapeutic footwear is recommended.

#2. In patients with plantar diabetic foot ulcer, the panel recommends off-loading with a total contact cast or irremovable fixed-ankle walking boot. For those with nonplantar wounds or healed ulcers, specific types of pressure-relieving footwear are recommended.

#3. In patients with a new diabetic foot ulcer, the recommendation is a probe-to-bone test and plain films, followed by MRI if a soft-tissue abscess or osteomyelitis is still suspected following the probe-to-bone test.

#4. Debridement is recommended for all infected ulcers, with treatment of those infections based on the 2012 guidelines published by the Infectious Diseases Society of America. The current document provides detailed recommendations on comprehensive wound care and various debridement methods.

#5. The panel recommends measurement of ankle-brachial index (ABI) in all patients with diabetes starting at age 50. Those at high risk by virtue of foot ulcer history, prior abnormal vascular exam, or intervention for vascular disease or known cardiovascular disease should have an annual vascular examination of the lower extremities and feet.

The full text of the guidelines can be read here.