How community pharmacists can help prevent diabetic foot amputations

Complications from diabetes, including foot amputations, are all-too common. Here's how pharmacists can help, writes Dan Howarth

Key learning points

One amputation every hour, 24 per day and 169 per week take place due to complications from diabetes
Such amputations are generally caused by unhealed ulcers and foot infections
Pharmacists can show patients how to check their feet for problems

Having diabetes increases people’s risk of developing serious problems with their feet. Every year, many thousands of people have a lower limb amputation related to their diabetes.

With diabetes affecting the circulation, resulting in blood not being able to flow to the feet and legs properly, people living with the condition can have problems with cuts and sores healing. Diabetes can also damage the sensation in the feet – not noticing wounds could lead to foot ulcers, infections and, at worst, amputations.

However, many of these amputations are avoidable. If people take good care of their feet and check them regularly, they can reduce this risk. Community pharmacists play an important role in ensuring that any symptoms are caught early and can be a trusted voice for people living with diabetes, providing valuable advice on how to look after their feet. Here’s how you can help.

Diabetes and feet

With 169 amputations taking place each week because of diabetes – that is 24 amputations a day, or one amputation every hour – it’s incredibly important for people to check their feet and legs, both themselves and with the support of a healthcare specialist.

Unhealed ulcers and foot infections are the leading cause of diabetes-related amputations, with diabetic foot ulcers preceding more than 80% of amputations. This is an alarming number, particularly considering it doesn’t have to be that way.

Most amputations caused by diabetes can be prevented, and one of the ways pharmacists can help is by encouraging patients to attend their annual foot checks. They can also inform them what signs to look out for every day.

15 healthcare essentials

Pharmacists can help to inform people with diabetes about the level of care they are entitled to. For instance, people’s management of diabetes should always include the 15 healthcare essential checks that they are entitled to for free through the NHS.

These are:

Blood glucose test (HbA1c test)
Blood pressure check
Cholesterol check (for blood fats)
Eye screening
Foot and leg check
Kidney tests
Advice on diet
Emotional and psychological support
Diabetes education course
Care from diabetes specialists
Free flu jab
Good care if you’re in hospital
Support with any sexual problems
Help to stop smoking
Specialist care if you’re planning to have a baby.

It is important for pharmacists to educate and support people with diabetes to get these thorough annual health checks done, with their annual foot and legs checks being no exception.

Acting quickly in the event of an emergency can make a big difference and can prevent the devastating consequences of complications that, in the case of ulcers, includes amputation. Indeed, this check can be the difference between keeping and losing a foot.

How to test for sensitivity in feet

Pharmacists should also encourage people to check the sensitivity (or feeling) in their feet at home on a regular basis. Sensitivity is one way in which our bodies alert us to other problems.

Here’s an easy step-by-step guide that you could run your patients through to help them test the sensitivity in their feet.

In order to do the test, they will need someone to help them by touching six of their toes – three on each foot. They then write down how many of the touches they feel. The touch must be as light as a feather, and for no more than a second. They also shouldn’t touch each toe more than once.

Testing for sensitivity at home:

Take off your socks and shoes and get comfy by lying down on a sofa or bed.
The helper will then remind you which is your right and which is your left leg. They'll do this by firmly touching each leg and saying, “This is your right” and “This is your left”.
Close your eyes and keep them closed until the end of the test. All you have to do is say ‘right’ or ‘left’ as soon as you feel a touch on your right or left toes.
The helper will now lightly touch the patient’s toes using their index (pointing) finger. They'll do this for these six toes in this order: right big toe; right little toe; left big toe; left little toe; right middle toe; left middle toe.
You say ‘right’ or ‘left’ if you feel the touch. If you do have a loss of sensation you won't feel the touch.
Your helper will write down whether you've felt a touch or not.

That is not to say that people should only check their feet if help from a third person is available. Checking your feet regularly is an incredibly important part of diabetes-related foot care.

What to look out for

Community pharmacists can remind patients to check their own feet daily. If they notice anything odd, including discoloured areas, hard skin, bruises or cuts and sores that haven’t healed properly, they should have their feet checked immediately by a healthcare professional.

Minor problems with the patient’s feet could quickly become something very serious, so here’s a full list of what signs your patients should look out for:

Tingling sensation or pins and needles (like numbness)
Pain (burning)
A dull ache
Shiny, smooth skin on the feet
Hair loss on the legs and feet
Loss of feeling in the feet or legs
Swollen feet
Their feet don't sweat
Wounds or sores that don’t heal
Cramp in their calves when resting or walking.

If any of the above symptoms are noticed, it’s really important that patients:

Take the weight off their affected foot
Contact their GP or foot protection team immediately
Go to their nearest out-of-hours healthcare service if the GP or foot protection team aren’t available.

However, people should seek urgent medical attention rather than waiting to see their GP, if they experience any of the following symptoms:

Changes in the colour and shape of their feet
Cold or hot feet without any obvious reason for the change in temperature
Blisters and cuts that they can see but don’t feel
Foul smell coming from an open wound.

10 simple steps to prevent foot problems

Pharmacists are in a position to provide sound healthy living advice, for example on how to stop smoking or how to follow a healthy lifestyle, which can help people manage their condition more effectively and reduce their risk of complications.

Apart from suggesting daily checks of their feet and legs to your patients, you could also help advise them to take a few additional simple steps to ensure they keep their feet healthy, including:

Getting help to quit smoking
Managing blood sugars, cholesterol and blood pressure
Eating a healthy, balanced diet and staying active
Watching out while cutting their nails
Making sure their footwear fits
Using moisturising cream every day
Avoiding using blades or corn plasters
Getting expert advice when problems arise
Keeping useful numbers handy
Asking someone to assess the feeling in their toes by doing the Touch the Toes test

It is vital that all people living with diabetes know how to look after their feet, and check them regularly to look out for the signs of foot problems. It is also crucial that people with diabetes know how important it is to seek medical attention if they spot any pf the signs of foot problems mentioned, and these are all things that community pharmacists can be of great help in making their patients aware of.

So, to help make that difference and help prevent amputations, use every opportunity to show people with diabetes what they should check for to reduce their risk of developing foot problems. You can also help advise of appropriate steps when symptoms appear, such as urgently seeing a healthcare professional – be it the patient's GP or specialist diabetes team.

At the end of the day, diabetes care should be a multidisciplinary team approach and GPs, specialist diabetes teams and pharmacists alike should all work together to ensure the best care for people with diabetes.

Dan Howarth is head of care at Diabetes UK