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Complications from diabetes can affect virtually every part of the body. The diabetic foot is of particular concern. With proper care, regular examinations, and properly fitting footwear (in conjunction with appropriate glycemic control), ~50% of amputations can be prevented.
Uncontrolled diabetes leads to foot complications through several mechanisms. Progressive neuropathy leads to a loss of sensation in the feet to the point where a patient may not feel heat, cold, friction, or sores. Patients with diabetes also experience impaired circulation to the lower extremities, which prevents wounds from healing appropriately and thereby increases the risk of infection.
Prevention of these complications starts with patient education. Pharmacists should take the opportunity to counsel all diabetic patients regarding several important points, which include the following:
Poorly fitted shoes are a primary cause of foot ulcers in patients with diabetes. Some of these patients will be able to find comfortable off-the-shelf shoes. They should try, however, to find an experienced shoe fitter, and make sure that their feet are measured each time they purchase new shoes. The shoes should fit properly in both the length and the width, with adequate room for the toes. Properly fitted shoes should not require a break-in period but should feel comfortable when purchased.
Pharmacists have a unique opportunity to help Medicare patients who have a need for therapeutic shoes. Medicare's therapeutic shoe program will cover 80% of the allowable cost for 1 pair of shoes each year for those diabetic patients who qualify. Typically, a patient's secondary insurance carrier will cover the remaining 20%. Simply being diagnosed with diabetes is not enough to qualify for the program, however. A patient must be in a diabetes treatment plan and have at least 1 of the following:
The therapeutic shoe prescription must be written by a podiatrist or a trained physician who is familiar with fitting shoes for patients with diabetes. Qualified patients are limited to the following per calendar year:
Community pharmacists have the opportunity to speak with patients regarding healthy foot care and the importance of obtaining properly fitted shoes. If patients might qualify for the Medicare therapeutic shoe program, they should be informed about their options and helped with referrals to their appropriate health care provider. Many patients who could truly benefit from the program are unaware that it even exists.
Dr. Brian is a clinical specialist with Cornerstone Health Care, High Point, NC.