With the right knowledge, they can conduct self-examinations and adhere to clinical trials.
Pharmacists are no strangers to the increasing prevalence of diabetes, but many are unaware that 15% to 25% of patients develop foot complications, so they should keep several points in mind when offering counseling.1
Diabetic foot ulcers, infections
Since diabetic neuropathy tends to develop in these patients, they lose pedal sensation. Diabetic foot ulcers are open sores usually located on the bottom of the foot due to foot deformities, irritation and poor circulation.2.3 When any of these risk factors exist, patients should consistently manage their foot care through self-examination and quarterly clinical examinations.
Patients can avoid further complications of diabetes. Elevated blood glucose levels, common in diabetic patients, can prevent foot ulcers from healing, which can lead to diabetic foot infections. These infections, defined as an infection of soft tissue or bone under the malleoli (the protrusion on either side of the ankle joint), are classified as mild, moderate, or severe.4 If cuts and scrapes are not treated, life-altering and life-threatening infections are possible. Most importantly, diabetic foot infection is the most common cause of diabetes-associated lower extremity amputation.3.4 Prescribers may use antibiotics to treat mild infections. However, as the severity of the infection increases, so does the severity of the procedure.4
Proper debridement can prevent foot ulcers from developing into serious infections.2 Because patients with diabetes are at greater risk of complications leading to higher health care costs, prevention is key in diabetic foot care. The recommendations of the American Diabetes Association (ADA) and the CDC on foot screenings and foot hygiene education run parallel.5 The ADA also compiled a 0 to 3 risk rating for diabetic foot with recommendations and aftercare.5 Table 15 lists the ADA recommendations based on risk classification.
The National Institute of Diabetes and Digestive and Kidney Diseases suggests that a diabetes care plan including a podiatrist is vital to patient health.6.7 table 28 gives examples of advice that pharmacists should communicate to all patients.
Diabetic Foot Infection Treatment Recommendations
Patients with foot problems often ask for help from pharmacists. It is important to understand the steps necessary to ensure patient health and safety.
The formation of calluses and corns is common in people with diabetes. Salicylic acid is a widely available OTC product that is useful for treating it, but patients with diabetes should not self-treat. Instead, they can soak in warm water for about 5 minutes to soften and gently remove dead tissue.8 If patients seek pain relief, pharmacists may recommend using cushioning pads in shoes to eliminate pressure.8 Self-Treatment Guidelines
for ingrown toenails also exclude patients with diabetes. Pharmacists can advise on how to trim nails correctly to prevent ingrown nails and to ensure that patients see a podiatrist regularly.8
The initial antibiotic regimens for foot infections are empirical.4.9 Once cultures of the infected wound are available, healthcare providers can streamline therapy. For mild infections, amoxicillin clavulanate and cephalexin are acceptable options.9 In the early 2000s, the FDA approved ertapenem, linezolid, and piperacillin-tazobactam for the treatment of complicated diabetic foot infections.9 Although the duration of treatment is based on severity, most patients’ infections resolve within 1 to 2 weeks. Infections associated with osteomyelitis typically require 4 to 6 weeks of therapy. Severe diabetic foot infections require surgical intervention. The Infectious Diseases Society of America (IDSA) recommends patients with diabetes receive wound care, including debridement, pressure redistribution, and wound dressing.9 IDSA guidelines emphasize that diabetic foot care teams should include a clinical microbiology specialist, an infectious disease specialist, and a surgeon.9
Patients taking antibiotics may experience digestive problems such as loss of appetite, nausea, and vomiting. Pharmacists should advise patients to avoid alcohol, take medication as prescribed whole, and use probiotics.10 Pharmacists have a responsibility to encourage patient adherence for the duration of therapy to prevent recurrence of the infection.
Foot care is extremely important for all patients with diabetes. An important facilitator of diabetes foot care is patient education. With the right knowledge, patients can conduct self-examinations and adhere to their clinical trials. Pharmacists are crucial in this process and can successfully promote positive preventive care practices.
About the author
Karisse Lora is a PharmD Candidate at the University of Connecticut School of Pharmacy at Storrs.
1. Yazdanpanah L, Shahbazian H, Nazari I, et al. Incidence and risk factors of diabetic foot ulcers: a population-based diabetic foot cohort (ADFC study) – two-year follow-up study. Int J Endocrinol. 2018;2018:7631659. doi: 10.1155/2018/7631659
2. Frequently Asked Questions: Diabetic Foot Ulcers. University of Michigan Health. Accessed July 11, 2022. https://www.uofmhealth.org/conditions-treatments/podiatry-foot-care/frequently-asked-questions-diabetic-foot-ulcers
3. Bandyk DF. The diabetic foot: pathophysiology, evaluation and treatment. Semin Vasc Surg. 2018;31(2-4):43-48. doi:10.1053/j.semvascsurg.2019.02.001
4. Gemechu FW, Seemant F, Curley CA. Diabetic foot infections. Am Fam Arts. 2013;88(3):177-184.
5. Boulton AJM, Armstrong DG, Kirsner RS, et al. Diagnosis and treatment of diabetic foot complications. American Diabetes Association; 2018.
6. Song K, Rooms AR. Diabetic foot care. In: StatPearls. Stat Pearls Publishing; May 1, 2022.
7. Diabetes and your feet. CDC. Updated May 7, 2021. Accessed July 11, 2022. https://www.cdc.gov/diabetes/library/features/healthy-feet.html
8. Srivasta SB. Minor foot disorders. In: Berardi RR, ed. Handbook of Nonprescription Medicines: An Interactive Approach to Self-Care. 20th ed. American Pharmacists Association; 2009.
9. Lipsky BA, Berendt AR, Cornia PB, et al; Infectious Diseases Society of America. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-e173. doi:10.1093/cid/cis346
10. How to Reduce the Side Effects of Antibiotics. UPMC Health Beat. January 8, 2016. Accessed July 11, 2022. https://share.upmc.com/2016/01/how-to-reduce-side-effects-of-antibiotics/