Eric Johnson, MD Florence Warren, DO Neil Skolnik, MD Jay H. Shubrook, DO Altru Diabetes Center, Grand Forks, ND (Dr. Johnson); Abington-Jefferson Health, Abington, Pa (Dr. Warren); Temple University School of Medicine, Philadelphia, Pa (Dr. Skolnik); Touro University, Vallejo, Calif (Dr. Shubrook) jay.shubrook@tu.edu
Dr. Johnson serves on the Novo Nordisk Speakers’ Bureau and on an advisory panel for Sanofi. Dr. Skolnik serves on the AstraZeneca Speakers’ Bureau and has served on advisory panels for AstraZeneca, Boehringer Ingelheim, Eli Lilly and Company, Novartis, Sanofi, and Teva. Dr. Shubrook has received research support from Sanofi and served as a consultant to Eli Lilly and Company, Novo Nordisk, AstraZeneca and GlaxoSmithKline. Dr. Warren reported no potential conflict of interest relevant to this article.
The presence of retinopathy is not a contraindication to aspirin therapy for atherosclerotic cardiovascular disease prevention, as aspirin does not increase the risk of retinal hemorrhage.
FOOT CARE/PERIPHERAL ARTERIAL DISEASE
What does the ADA recommend regarding foot care for patients with diabetes?
The ADA’s standards recommend an annual comprehensive foot examination to identify risk factors predictive of ulcers and potential amputations. The exam should start with inspection and assessment of foot pulses and should seek to identify loss of peripheral sensation.The examination should include inspection of the skin, assessment of foot deformities, neurologic assessment including 10-g monofilament testing and pinprick or vibration testing or assessment of ankle reflexes, and vascular assessment, including pulses in the legs and feet.40
It is also important to screen patients for peripheral arterial disease (PAD), with a comprehensive medical history and physical exam of pulses. Ankle-brachial index testing (ABI) should be performed in patients with signs or symptoms of PAD, including claudication or skin and hair changes in the lower extremities. ABI may be considered for all patients with diabetes starting at age 50 and in those younger than 50 years who have risk factors.41
Which patients with diabetes are at higher risk for foot complications?
The following are risk factors for foot complications: previous amputation, prior foot ulcer, peripheral neuropathy, foot deformity, peripheral vascular disease, visual impairment, peripheral neuropathy (especially if on dialysis), poor glycemic control, and smoking. Patients with high-risk foot conditions should be educated about their risk and appropriate management.
A well-fitted walking shoe that cushions the feet and redistributes pressure is one option to help patients. Patients with bony deformities may need extra wide or deep shoes and patients with more advanced disease may need custom-fitted shoes.
When should patients be referred to a foot specialist?
Refer patients to a foot care specialist for ongoing preventive care and lifelong surveillance if they smoke or have a history of lower-extremity complications, a loss of protective sensation, structural abnormalities, or PAD.
The ADA also recommends that patients ages 19 to 59 years receive the hepatitis B vaccine if they haven't already done so and that the vaccine be considered for those ≥60 years, as well.
IMMUNIZATION
Are there special immunization recommendations for people with diabetes?
No. Children and adults with diabetes should be vaccinated according to age-related recommendations for the general population, the standards state. The ADA also recommends that patients ages 19 to 59 years receive the hepatitis B vaccine if they haven’t already done so and that the vaccine be considered for those ≥60 years, as well. This is in keeping with the Centers for Disease Control and Prevention’s recommendation that adults with any medical, occupational, or other risk factor be immunized against hepatitis B.42
CORRESPONDENCE Jay H. Shubrook, DO, Touro University, 1310 Club Drive, Administration and Faculty 1, Room 117, Vallejo, CA 94592; jay.shubrook@tu.edu.
