Practical guidelines on the prevention and management of diabetes‐related foot disease (IWGDF 2023 update)

Abstract

Diabetes‐related foot disease results in a major global burden for patients and the healthcare system. The International Working Group on the Diabetic Foot (IWGDF) has been producing evidence‐based guidelines on the prevention and management of diabetes‐related foot disease since 1999. In 2023, all IWGDF Guidelines have been updated based on systematic reviews of the literature and formulation of recommendations by multidisciplinary experts from all over the world. In addition, a new guideline on acute Charcot neuro‐osteoarthropathy was created. In this document, the IWGDF Practical Guidelines, we describe the basic principles of prevention, classification and management of diabetes‐related foot disease based on the seven IWGDF Guidelines. We also describe the organisational levels to successfully prevent and treat diabetes‐related foot disease according to these principles and provide addenda to assist with foot screening. The information in these practical guidelines is aimed at the global community of healthcare professionals who are involved in the care of persons with diabetes. Many studies around the world support our belief that implementing these prevention and management principles is associated with a decrease in the frequency of diabetes‐related lower‐extremity amputations. The burden of foot disease and amputations is increasing at a rapid rate, and comparatively more so in middle to lower income countries. These guidelines also assist in defining standards of prevention and care in these countries. In conclusion, we hope that these updated practical guidelines continue to serve as a reference document to aid healthcare providers in reducing the global burden of diabetes‐related foot disease.

Diabetic Foot Ulcers

“…To assess the risk of ulceration in a person with diabetes, the feet are screened annually by a primary care clinician or podiatrist; the screening should include evaluating the feet for neuropathy sufficient to cause loss of protective sensation, peripheral artery disease, and skin breakdown . Among patients with a new diabetic foot ulcer, those who had been seen by a podiatrist for preventive care in the year before ulcer development had a lower risk of major lower extremity amputation relative to those who had not seen a podiatrist in the past year (1.20% vs 1.84%; OR, 0.61 [95% CI, 0.51-0.72]; P < .001) .…”

“…Individuals with diabetes are assessed for loss of protective sensation as a sign of large fiber neuropathy . The Semmes-Weinstein 5.07 monofilament test to assess for absence of pressure sensation at a minimum of 3 sites per foot (likelihood ratio for ulceration range, 11-16) or the 128-Hz tuning fork to assess for absence of vibratory perception (using an on-off technique or timed methods; likelihood ratio range, 16-35) are important components of this assessment . In the absence of this equipment, the Ipswich Touch Test is an acceptable alternative that can be used to evaluate whether a patient can perceive light touch from an examiner’s index finger applied to 6 or 8 prespecified sites on the feet (likelihood ratio range, 10-15) …”

“…People in the lowest foot ulcer risk category without loss of protective sensation, peripheral artery disease, or history of foot complications may return for annual follow-up with a primary care clinician or podiatrist (Table 1). People with diabetes who have an increased risk of foot ulceration should receive education about proper foot self-care and appropriate footwear . People with 2 or more risk factors among loss of protective sensation, peripheral artery disease, and foot deformity are considered at moderate risk and should have a shoe specialist consultation (from a podiatrist, pedorthist, or orthotist) for good-quality footwear with appropriate fit that may include therapeutic footwear to reduce pressure .…”

“…Immediate vascular referral is indicated for patients with a diabetic foot ulcer and an ankle pressure less than 50 mm Hg, an ankle-brachial index less than 0.5, a toe pressure less than 30 mm Hg, or a transcutaneous oxygen pressure less than 25 mm Hg . Vascular surgery referral should also be considered, regardless of results of vascular study, for patients with peripheral artery disease and a nonhealing diabetic foot ulcer that persists for 4 to 6 weeks despite evidence-based care consisting of pressure off-loading and wound debridement . People with a diabetic foot ulcer that has resolved or who have undergone partial foot amputation for diabetic foot ulcer are in the highest risk category (also called remission).…”

Exploration of the common pathogenic link between COVID‐19 and diabetic foot ulcers: An in silico approach

“…As one of the most important healthcare problems, diabetes is estimated to affect 536.6 million people in 2021 and reach 783.2 million by 2045 8 . Diabetic foot ulcer (DFU) is a multifactorial clinical problem defined by the International Working Group on the Diabetic Foot as a set of symptoms secondary to current or previous diabetes, including skin ulceration, neuropathy, infection, or destruction of the lower extremities 9,10 . It is one of the most commonly observed and severe chronic complications of diabetes, with a global prevalence of 6.3% 11 .…”