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Australian and International Guidelines on the prevention of diabetic foot ulcers

This is the third article in the “DFA Guides You Through” series on Australian and International diabetic foot disease guidelines.

Prevention has long been the Cinderella of diabetic foot disease, receiving scant attention in research and guidelines. While it is still underrepresented in research (of the last 100 published RCTs on diabetic foot disease only 6 focus on prevention, yet 62 target healing), the new IWGDF guidance finally makes up for this with a chapter dedicated to this topic. While the Australian guideline appears to focus more heavily on prevention, with chapter B on risk assessment and chapter C on prevention, the content and the recommendations of both chapters provide less detail. The aim of this article is to present the similarities and differences in both guidelines with regard to risk assessment and prevention of diabetic foot ulcers.

Both guidelines are largely similar in their approach to risk assessment and screening frequencies. Peripheral neuropathy, peripheral artery disease, foot deformities, and ulcer/amputation history are identified as the most important risk factors in both. Based on these risk factors, 3 (Australian) or 4 (IWGDF) risk stratification groups are identified. IWGDF advocates a screening frequency of 1-3 months for people in the highest risk group, compared to 3-6 months in the Australian guideline. However, both acknowledge that this frequency is based predominantly on expert opinion as no evidence is available to indicate superiority of one screening frequency over another.

Although the risk assessment and screening recommendations are very similar, the recommendations with regard to prevention interventions show some differences. The IWGDF has 11 recommendations that deal with the topics of foot care, education, footwear, self-management and surgical interventions; whilst the Australian guideline has 3 recommendations concerning foot care and education.

For each of these topics, similarities and differences are:

  • Foot care: both guidelines stress the importance of an integrated foot protection program that includes education, treatment and footwear. The specific components of protective treatment by a podiatrist or other suitably trained health care worker are described in a little more detail in the IWGDF guideline, based on expert opinion.
  • Education: both guidelines provide cautious recommendation that patient education should be provided for the prevention of foot ulcers, based on expert opinion due to the absence of high-quality evidence on patient education. Although, we do not know what the best form of education is, both guidelines have placed it as part of integrated foot care (see above).
  • Footwear: while no recommendation was made in 2011 in the Australian guideline, new evidence has appeared in the last four years driving the IWGDF recommendations. Based on this evidence, therapeutic footwear with a demonstrated plantar pressure relieving effect is recommended for the prevention of recurrent plantar foot ulcers. This adds weight to the need to update the Australian guideline on this specific topic.
  • Self-management: the only self-management intervention supported by any evidence in either guideline is home-based foot skin temperature monitoring. Three RCTs support its effectiveness in the prevention of foot ulcers. The translation of this evidence into recommendations, however, differs between guidelines. A positive recommendation supporting home-based foot skin temperature monitoring is made in the IWGDF guidance, whilst no recommendation is made in the Australian guideline. The Australian guideline’s technical report sheds light on why no recommendation was made, stating: “the expert working group felt there was insufficient evidence (due to small sample sizes)”. This appears a little unusual, as the sample sizes in these RCTs were 225, 173 and 85, which is larger compared to various other interventions that are recommended in the Australian guideline. As this self-management intervention could be suitable for Australia’s vast rural and remote areas, this intervention should perhaps be reconsidered in any update of the Australian guideline.
  • Surgical interventions: no recommendations are made on surgical interventions in the Australian guideline, as these were not part of their scope of work. However, the IWGDF positively recommends considering Achilles tendon lengthening and flexor tenotomy, and a recommendation against nerve decompression is given. Any surgical intervention presents the risk of complications, but also the advantage of permanently changing foot shapes to reduce plantar pressure without the need for any treatment adherence. With increasing evidence on this topic, it should perhaps be considered for inclusion in the scope of work of any Australian update.

The overview of all recommendations in both guidelines can be found in this table.

In conclusion, both guidelines recommend similar risk assessment, stratification schemes and integrated foot protection programs. The main differences result from additional IWGDF recommendations based on new evidence or evidence in fields outside the scope of work of the Australian guideline; particularly for footwear, home-based foot skin temperature monitoring and some surgical interventions. The new evidence behind these IWGDF recommendations suggests these should be very relevant areas for consideration in any future Australian guideline update.

In the next article of this “DFA Guides You Through” series, we will discuss the specific recommendations on the management of foot ulcers.

Return to DFA guides you through series.

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