Proactive Measures To Prevent Diabetic Complications
In spite of efforts to control diabetes and improve limb salvage rates, the number of diabetes-related amputations continues to rise in the United States. Over 80,000 amputations are performed each year, with approximately one-half being partial foot procedures and one-half being transtibial or higher amputations.1 By evaluating and identifying patients at risk for amputation, podiatrists may initiate simple, preventive interventions that can help lower these dismal statistics.
Patients with diabetes suffer from macrovascular and microvascular complications. Any of these complications can increase the risk of serious foot problems. Accordingly, podiatric physicians should be aware of these systemic disorders and encourage their patients to comply with measures to control these disease processes.2
Macrovascular complications affect the larger vessels and include coronary artery disease (CAD) and peripheral vascular disease (PVD). Although patients with diabetes are believed to be more susceptible to these conditions than the non-diabetic population, glucose control alone may not alter the course of these diseases. Medical interventions include exercise, the prevention of thrombosis with aspirin or other medications, control of hypertension and lipid management.
During the podiatric office visit, one should provide hypertension screening and encourage compliance with blood pressure control measures. One can refer undiagnosed or uncontrolled blood pressure to the internist for intervention. Any blood pressure in excess of 130/80 requires further evaluation.
Podiatrists can also provide screening for peripheral arterial disease (PAD) via a Doppler examination and determining the patient’s ankle-brachial artery index (ABI) can facilitate the detection of coronary artery disease (CAD). There is a 20 percent risk of a non-fatal cardiac event within five years in patients with PAD and a 30 percent mortality risk within five years of diagnosis in these patients even if they have not suffered from critical limb ischemia or amputation.3
Microvascular complications include retinopathy, renal disease and neuropathy. These appear to be directly related to hyperglycemia. Tight glucose monitoring and control is now the standard of care for both type 1 and type 2 diabetes. Encouraging compliance with such a regimen should be part of the podiatric office visit.
Severe signs of neuropathy, such as profound numbness or ulceration, are indicators of poor control. Office evaluation of blood glucose or hemoglobin A1c may provide laboratory evidence of poor control. One must encourage patients to monitor and report their glucose levels to their physicians and obtain appropriate management to optimize their blood glucose levels. Referring the patient to an endocrinologist may be appropriate if the primary physician is unable to normalize the glucose levels.
The clinic or office visit consists of identifying patient complaints and obtaining a pertinent history. Clinicians must document foot complaints and comorbidities such as renal disease or CAD, review the patient’s current medications and assess his or her glucose control. The podiatric physical should include at least a brief vascular and sensory evaluation. While a detailed examination of these systems is not necessary at every visit, one should perform it once or twice a year depending on the individual patient. In particular, note the presence or absence of ulcer or ulcerative lesion. Be sure to document the diagnosis and risk assessment.
Focal Pressure Keratosis: A Common Precursor To Ulceration
In a position statement on diabetic foot care, the American Diabetes Association (ADA) has identified four conditions that are associated with an increased risk of amputation.4 These conditions include: