Tips for managing foot disease in diabetes during COVID-19
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Foot complications of diabetes typically require face-to-face consultations and treatment, presenting several unique challenges for clinicians during the COVID-19 pandemic.
Individuals with diabetic foot disease tend to have multiple comorbidities, making them among the most susceptible to worse COVID-19 outcomes, including hospitalization, intubation and death. At the same time, resources for outpatient management, such as X-rays and bloodwork, have been limited during the pandemic, clinic hours have been reduced and reliance on telemedicine has increased.
In a review published in May in Diabetes Care, Andrew J.M. Boulton, MD, DSc (Hon), FACP, FICP, FRCP, president of the International Diabetes Federation, professor of medicine at the University of Manchester and a past-president of the European Association for the Study of Diabetes, and colleagues outlined approaches to diabetic foot problems from two centers — the Royal Infirmary in Manchester, United Kingdom, and the Southwestern Academic Limb Salvage Alliance at the Keck School of Medicine of USC in Los Angeles— and compared how challenges were met to treat patients and avoid hospitalization.
Healio spoke with Boulton about how the pandemic has led to a back-to-basics approach to managing diabetic foot disease, and how that may ultimately change treatment going forward.
What led you and your colleagues to write this article?
Boulton: I have been working on the diabetic foot for 40 years now. In the beginning of the lockdown, in March, we were told we lost all routine investigations. We couldn’t do X-rays or blood tests, check C-reactive protein, blood count, any markers at all or any imaging. We are back to good, clinical medicine, where I look at the patient with a foot problem and I decide, on clinical grounds, what needs to be done. Because of years of experience, we seem to have been successful.
You titled this article “A Tale of Two Cities.” What were you and your colleagues trying to convey to readers?
Boulton: We wanted to compare and contrast what was happening in the U.S. vs. the United Kingdom. In Manchester, our patients were frightened to come and see us in the hospital, and rightly so. If you look at who is at risk for developing problems with diabetes and COVID-19, it’s mostly older men with poor glycemic control and other complications. Those are the exact people who are going to have diabetic foot problems. I moved all of my consultations from the hospital clinic to the community clinic. Many people are taking advantage of that. Last week, for example, I saw 57 patients on an outpatient basis, away from the hospital. We have been treating these people based on clinical signs. I had a patient, for example, I thought he had osteomyelitis. He had the clinical signs of it: inflamed toe, wound that approaches bone. I couldn’t do an X-ray or any blood test. I treated him with broad spectrum antibiotics. Once we were finally able to do an X-ray, we saw radiological healing. Without any tests, we were able to succeed. The surgeons were about to take his toe, and I told him the pandemic saved him from losing his toe. It is never too late to learn.
What are the most important take-home messages for clinicians right now who are seeing these patients with limited resources?
Boulton: First is use good clinical observation and good clinical practice. You can do a lot via video call. You can see the problem. My colleagues in Los Angeles, for example gave instructions to a home visiting nurse on how to apply maggot therapy for a chronic wound, which succeeded. You still need face-to-face visits for patients who need debridement therapy and so on. You cannot do that virtually.
Second is use the resources you have. One of the cases from Los Angeles involves local surgery for a patient who was too frightened to go to the hospital. The clinician saw the patient in a peripheral clinic setting. With local anesthesia he was able to do the needed surgery and save the foot. Good clinical practice, using clinical acumen and observation, plus whatever tests we can do, is still very helpful. When you examine the foot, what matters most is to look and see. The tests confirm what you see.
What have you done to work out the more difficult issues with telemedicine?
Boulton: If you are a clinician who is unsure what you might be dealing with via telemedicine, you bring the patient to a clinic away from the hospital. People are rightly afraid of COVID-19. There have been, sadly, some disasters. One patient was too frightened to go to hospital — he had had a transplant and was very high risk — and he ended up losing his leg because he should have come earlier. Clinicians must strike a balance between essentials and decide what can be managed sensibly and conservatively away from the inpatient setting.
You have written about people with diabetic peripheral neuropathy losing “the gift pain” and how dangerous that can be. How does that compound risk for people with diabetes during a pandemic?
Boulton: We have learned with diabetic neuropathy that people do lose the gift of pain. They no longer have the warning system to tell them something is wrong. Someone can walk on a fracture and develop Charcot foot. We have seen that patient. That is why, during this time, a hot, swollen foot is a Charcot foot, until proven otherwise. If the patient has no pain, but the foot is hot and swollen, we put them in a cast. We have done this and then, when we are able to do an X-ray months later, we see we were right. It is all about good clinical training and observation. Sadly, some clinicians today have not had that experience.
Once we are on the other side of this, how will this pandemic change the way you practice medicine?
Boulton: The patients I would have sent for surgery — say for osteomyelitis, septic arthritis — I would now consider treating with antibiotics alone. In the neuropathic world, I will be less likely to refer to surgery. There is support for this. A study in The New England Journal of Medicine demonstrated that oral antibiotics for osteomyelitis are just as good as IV antibiotics. We don’t need the IV drugs at home. These patients have been treated with oral antibiotics during this time and have done well. Then, we get the X-ray and see they have done well, and there is evidence of healing, radiologically. They do well and still have five toes. I have learned a lot, and I am now more empowered to go for conservative therapy.
For more information:
Andrew JM Boulton, MD, DSc (Hon), FACP, FICP, FRCP, can be reached at aboulton@med.miami.edu.
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