Three to four hundred thousand people annually lose feet and legs in Pakistan due to diabetic foot ulcers-Prof. Abdul Basit


Proceedings of NADEP Diabetes FOOTCON 2019
Three to four hundred thousand people
annually lose feet and legs in Pakistan due
to diabetic foot ulcers-Prof. Abdul Basit
Complications of diabetes that affect the lower extremities
re common, complex, 
costly and associated with increased
morbidity & mortality-Prof.Dr.Roberto Anichini

By Mubarak Ali

KARACHI: Like elsewhere in the World, amputation of lower limbs due to diabetes is the leading cause of disability in Pakistan where according to an estimate, three to four hundred thousand people are annually losing their feet and legs because of ‘diabetic foot ulcers’, which is a serious but preventable cause of lower limb amputations. This was stated by Prof. Abdul Basit, Chairman of International Diabetes Federation (IDF) Middle East and North Africa (MENA) Region while speaking at two-day NADEP Diabetes Footcon 2019 held at a local hotel here from August 2-4, 2019. Topic of his presentation was overcoming the barriers in foot care.

From (L to R) Prof. Ejaz Vohra, Prof. Abdul Basit, Prof. Feroz Memon and Prof.
Tahir Hussain chairing scientific sessions during the two-day NADEP Diabetes
FOOTCON 2019 held at a local hotel in Karachi from August 2-4, 2019.

Continuing Prof. Basit said that in 2005, one person was losing his or her lower limb due to diabetic foot ulcer after every 30 seconds somewhere in the world but at the moment, this rate has increased and now after every 20 seconds, one amputation is being carried out somewhere in the World. Almost same is the situation in Pakistan and as per our estimates, three to four hundred thousand people annually lose their lower limbs due to diabetic foot ulcers. Prof. Abdul Basit further said that three thousand diabetic foot clinics are required throughout Pakistan to reduce amputations due to diabetic foot ulcers and to prevent the country from becoming a disabled nation. In Sindh, we have spoken to the provincial health department and have offered them to train their doctors so that they could provide training to healthcare providers and experts operating in rural areas where diabetes prevalence was as high as in the urban areas, he added. Prevalence of diabetes in Balochistan has increased up to 60 percent, more than double the overall prevalence of diabetes in Pakistan which is around 26 percent and called for more comprehensive studies to ascertain the causes of such a high prevalence of diabetes among people of Balochistan.

Overall diabetes prevalence in Pakistan Prof. Abdul Basit said is 26 percent but unfortunately, it is around 60 percent in Balochistan, which is very alarming. The reason behind such a high prevalence of diabetes in Balochistan according to local doctors is restricted movement of people due to law and order situation and absence of recreational facilities in the under-developed province of Pakistan. We conducted two researches in Hub town of Balochistan where we found diabetes and obesity on the rise among general population but there is a need to conduct comprehensive studies in entire Baluchistan, Prof. Abdul Basit added.

Prof. Dr. Roberto Anichini from Italy discussed the pathways of occurrence and recurrence of diabetic foot ulcer. Complications of diabetes that affect the lower extremities are common, complex, costly and associated with increased morbidity and mortality. Foot ulceration, he said, is the most frequently recognized complication. Prevention of foot ulcers in patients with diabetes is extremely important to help reduce the enormous burden of foot ulceration on both patients and health resources. What we we need is the better information for caregivers about effective prevention. Diabetic foot ulcers are commonly caused by repetitive stresss in patients with perepheral neuropathy in addition to Peripheral vascular disease which also contributes to the development of Foot ulcer.

Prof. Dr. Roberto further said that neuropathy leads to an insensitive and sometimes deformed foot, often causing abnormal loading of the foot. In people with neuropathy, minor trauma, from ill- fitting shoes, or an acute mechanical or thermal injury can precipitate ulceration of the foot. Loss of protective sensation, foot deformities, and limited joint mobility can result in abnormal biomechanical loading of the foot. This produces high mechanical stress in some areas, the response to which is usually thickened skin (callus). The callus then leads to a further increase in the loading of the foot, often with subcutaneous haemorrhage and eventually skin ulceration. Whatever the primary cause of ulceration, continued walking on the insensitive foot impairs healing of the ulcer.

Appropriate ulcer healing therapies include surgical debridement, off loading of pressure, effective management of infection and Vascular treatment (endovascular or surgical Procedure). Education of patients and organization of care pathway for different level of assistance to prevent first ulcer and recurrence is very important. Accreditation of team, Benchmarking and audit with other teams plays an important role in further improvement. Do not measure outcomes alone as amputation or as healing times of the ulcer,We also, have to deal with the events, morbidity and mortality and quality of life of patients with diabetic foot. Foot ulcers heal in many patients, and the need for amputation is averted, Prof. Dr. Roberto conclcuded.

Dr. Zulfiqar G. Abbass from Tanzania talked about Diabetic Foot Infection (DFI) - When to suspect and how to classify it. Approximately 40-60% of all non-traumatic amputations are done on the Lower Limbs and 85% of diabetes related lower extremity amputations are preceded by foot ulcer. Infection is the immediate cause of Amputation in 25-50% of Patients. With diabetes mellitus DFI is defined as soft tissue or bone infection anywhere below the malleoli in a person with diabetes. The burden of diabetic foot cannot be addressed without a discussion of infectious diseases. Foot infections are common, complex and serious problem in DM patients. Infections cause prolonged hospital admission costs. Diabetic foot ulcers in our continent is invariably infected and we have no podiatry/chiropody practice. The challenge is to find solution to the problems posed by diabetic foot diseases in poor resourced countries. Infection is the main pathway to necrosis. Early diagnosis and intervention is necessary and Diabetic foot infection must be diagnosed clinically based on the presence of local and systemic signs and symptoms of inflammation. Minor problem (superficial scratches or cellulites) can lead to limb threatening or life threatening conditions, he added.

 Prof. Abdul Basit, Prof. Roberto Anichini, Dr. Zulfiqar G. Abbas, Dr. Osman Faheem, Dr. Salma E Khuraibet,
Prof. Zaman Shaikh, Dr. Syed Hasnain Haider Shah, Dr. Zahid Miyan, Dr Fawad Ahmad Randhawa, 
Dr. Asim Bin Zafar, Dr. Musarrat Riaz and Ms Erum Ghafoor speaking at two-day NADEP Diabetes
FOOTCON 2019 held at a local hotel in Karachi from August 2-4, 2019.

Dr. Zulfiqar further said that Foot examinations should be performed in patients with diabetes at least once a year and more frequently in those at higher risk of foot ulceration. Identification of patients at risk of ulceration is the most important aspect of amputation prevention. Education is an integral part of prevention which should be simple and repetitive. Education should be targeted at all levels including healthcare providers, patients & relatives. Efforts are required to increase awareness of diabetes and its complications amongst the health workers and patients. Early detection and treatment of diabetes will improve course of disease and reduce morbidity and mortality. Willingness is not enough you must do, and Knowing is not enough you must apply he concluded.

Prof. Zaman Shaikh highlighted the latest update on cardiovascular safety of SGLT2i. At present eight medication classes for diabetes management are available which includes thiazolidinediones, metformin, glinides, sulfonylureas, GLP-I RA, DPP-4Is, alpha glucosidase-Is and SGLT2-Is. Mortality of diabetic patients is due to cardiac events, complications and there is a strong relationship between cardiovascular disease and diabetes mellitus. First SGLT2-I was approved by EMA in 2012 and got FDA approval in 2014. SGLT-2 help to remove excess glucose from blood through urine and helps to improve glycemic control. It results in improved HbA1C levels, thereby reducing the risk of complications due to decreased Gluco-Toxicity. There is a risk of developing ketoacidosis in patients who have altered kidney function. There is substantial reduction in the risk of clinically significant renal deterioration by Dapagliflozin. According to new updates of eGFR now Dapagliflozin can be given in moderate renal impairments. Ideal drug should have HBA1c reduction, preserve beta cells, BP control, weight reduction, and no major hypo, reduces CV risks, mortality and have renal benefits, reduce micro albuminurlla Prof. Zaman Sheikh concluded.

Dr. Salma E Khuraibet from Kuwait delivered a talk via skyp and discussed surgical aspects in diabetic foot disease. Knowledge of the anatomy she stated is essential so that progression of pathological changes in diabetic foot can be understood. Nails of foot protect fingers and toes from injury and trauma. Diabetics have decreased sensation in the fingers and toes, so it is critical that the nails are kept in good condition and nail examination is very essential. Diabetics are prone to developing fungal infection known as onychomycosis which accounts for approximately 50% of all nail infections. Unnoticed small cuts on the fingers and toes can be a portal for bacteria that leads to fungal infections. There are 26 bones in the human foot, 33 joints, 107 ligaments and 19 muscles and tendons and 52 bones in our feet make up about 25% of all the bones in the body.

Continuing Dr. Salma said that despite the efforts of conservative therapy there will always be a percentage of wound that will require surgical intervention in order to heal the wounds. Topically this involves elimination of infection, surgical procedures designed to off-load areas of increased pressure, improving diminished vascular flow or a combination of all of these. Peripheral arterial disease is a major limiting factor in wound healing, but through the efforts of a vascular surgery team many ischemic wounds can be converted to non-ischemic wounds. The main goal of surgical intervention with infection is to evacuate abscess, remove necrotic tissue and minimize the risk of further spread. The basic principles of surgical approach in treating the infection are incision, debridement, wound lavage and surgical closure. Curative surgical treatment of diabetic foot is to speed up the healing of the diabetic foot wounds and prevent recurrence of this wound. Surgical decision making is heavily dependent on the type of wound and its location. Majority of chronic ulcerations patients are result of increased plantar pressure in the presence of peripheral neuropathy. The surgical goal for these types of ulcers is to relieve the source of increase in pressure. Metatarsal head resection is often a better option in patients with open plantar foot wounds. This procedure prevents the use of hardware in an area with increased risk of infection and can reduce soft tissue tension allowing for the primary closure of plantar foot wounds.

 Prof. Bikha Ram, Prof. Yaqoob Ahmdani, Prof. Bilal Bin Younis and Prof. Jamil Ahmed chairing scientific
sessions during the NADEP Diabetes FOOTCON 2019 held at Karachi recently.

Trans-Metatarsal Amputation (TMA) is one of the most widely used procedure by a foot surgeon in the event of ischemic toes or pro-found infection, Dr. Salma E Khuraibet stated. Reduction of pressure, prevention of ulceration, increased function, relief of pain and allow for proper accommodation are the major goals of diabetic foot surgery. Risk factors for DFU include peripheral arterial disease, peripheral neuropathy, previous amputation, ulceration, presence of callus, joint deformity, problem with vision and mobility and male sex. There are four classes of diabetic foot surgery which includes elective, prophylactic, curative and emergent.

In her concluding remarks Dr. Salma E Khuraibet said that education including routine preventive podiatry care and use of appropriate foot ware are very important. The person should check the feet every day and report any sores or cuts that do not heal in addition to puffiness or swelling and any skin that feels hot to the touch. Control of glucose, blood pressure, cholesterol, smoking cessation and weight control must be taken care of. Mechanical foot interventions must be used to prevent ulceration and use of antibiotics to manage and prevent infections.

Dr. Fawad Ahmad Randhawa discussed the management of diabetes with next generation Insulin Co-Formulation. Variability in blood glucose, he opined, leads to patients experiencing periods of hyper- and hypoglycaemia. Lower variability in blood glucose means that a patient spends more of their time within the target FPG range, with fewer hyper- and hypoglycaemia excursions. The aim of premix insulin or a basal-bolus regimen is to accurately replicate the physiological insulin response with meal-time peaks and basal component. Current premix insulins replicate the physiological insulin response to some extent but are hampered by variability in glycaemic control, lack of 24-hour basal coverage and the need for re-suspension (increases the risk of intra-patient variability) A basal-bolus regimen is hampered by the need for multiple daily injections and complex titration schedules both of which can reduce patient’s willingness to adhere to their diabetes management.

The Ryzodeg (IDegAsp) co-formulation IGlar and IDet cannot be coformulated with bolus insulins. IGlar is designed to microprecipiate at pH4 while bolus insulin is only soluble at pH7.4, thereby creating a disconnect. IDet when coformulated can lead to the formation of mixed hexamers which distorts the PK/PD profile of the insulin. Co-formulation of IDeg with rapid-acting insulin is possible because of stable dihexamers in solution. This is the first ever trial to compare IDegAsp OD with basal-plus therapy which is represented here as comparison of apples with apples. Ryzodeg is delivered in the FlexTouch pen. The 80-unit maximum-dose pen contains IDegAsp 100 units/mL formulation and delivers up to 80 units per injection. It contains a total of 300 units per pen. The pen has no push-button extension and requires less pressure for injection. It offers once-daily dosing, Simple initiation and titration, Flexible dosing, Effective and predictable glucose- lowering profile.

Dr. Syed Hasnain Haider Shah from UAE talked about Neurointerventional Management of Diabetic Neuropathic and other Pain Syndromes. Diabetic sensorimotor polyneuropathy represents a diffuse symmetric and length-dependent injury to peripheral nerves that has major implications for QOL, morbidity, and cost from a public health perspective. PDN affects 18% of patients with diabetes, it is frequently unreported (12.5%) and more frequently untreated (39%). PDN presents an ongoing management problem for patients, caregivers, and physicians. Many treatment options are available, and a rational approach to treating patients with PDN requires an understanding of the evidence for each intervention. Pharmacologic agents and nonpharmacologic modalities are available for its management.

The goals of interventional pain management Dr. Syed Hasnain Haider stated are to relieve, reduce, or manage pain and improve a patient’s overall quality of life through minimally invasive techniques specifically designed to diagnose and treat painful conditions. Interventional pain management also strives to help patients return to their everyday activities quickly and without heavy reliance on medications. Neurostimulation is an effective method of pain control for many patients, it reduces or eliminates pain medications, Non-destructive and less invasive than surgical alternatives, reversible and can be discontinued or surgically removed.

Intrathecal Drug Delivery (IDD) Therapy benefits, Pain relief for patients who have not received adequate relief with conventional therapies, Reduction in adverse effects from oral opioids such as nausea, vomiting, sedation, and constipation, Decreased or elimination of oral analgesics, Increased ability to perform activities of daily living, Patient control within physician-set limits, May be effective for patients who do not experience relief from neurostimulation therapy. With today’s treatments, patients should not have to wait for effective pain relief, by partnering, we can help patients find the right pain treatment Together we can improve the quality of life for chronic pain patients and our decisions may change the course of a patient’s life, he added.

Dr. Zahid Miyan delivered a talk on Footwear for every diabetic – affordable and acceptable. He pointed out that they started limited footwear manufacturing at BIDE in 2015 with the aim to improve access to footwear for everyone, everywhere and developed the concept of standardized, low cost, durable and acceptable footwear for people with diabetes. The programme was expanded by establishing sustainable footwear facilities in the country, provided training manual for therapeutic footwear and built capacity in footwear manufacturing for people with diabetes. “Train the Trainer Programme” was initiated. Diabetic footwear that is currently available in the market is very expensive because of imported material. We provided locally made shoes in the range of Rs.1400 to 3000 rupees as compared to earlier available shoes which were costing around Rs. 8000 to 20,000. We have now introduced attractive custom-made designs in wide range of colors. Trial for Size on same day has been arranged to save the time of the patients.

Footwear for every diabetic Dr. Zahid stated is new concept in this part of the World. With the support of WDF we have been able to implement the concept. Replication of the FLRIT – BIRD model in many of low resource and middle income countries according to their local requirements is needed. Collective efforts by all stake holders for resource development is the call of the day for care of people with diabetes, Dr. Zahid Miyan added.

Dr. Asim Bin Zafar gave a detailed presentation on Peripheral Arterial Disease (PAD) among people with diabetes, saying it is the biggest cause of foot ulcers in diabetics. Now with the help of latest technology and use of intervention radiology, this condition could be treated and lower limbs amputation could be prevented. He presented the cases of PAD managed at BIDE Foot clinic through collaboration of multiple stakeholders. He also informed about the development of PAD registry, the first of its kind in Pakistan by BIDE. To further increase the collaboration between different centers of Pakistan, weekly online foot meeting is conducted where complicated cases are seen and exchange of ideas and suggestions by experts of the field Pan- Pakistan leads to better management protocols. He invited all those Health care professionals (HCPs) interested in diabetic foot management to join PAD Whats App group to take advantage of this learning opportunity.

Concluding session

Speaking in the concluding session of the foot conference, Prof. Abdul Basit, President IDF MENA Region, urged the nutritionists to come up with diet plans in accordance with local needs and requirements of Pakistani people, saying food and stuff eaten in Europe could not be advised to people in Pakistan. We are soon going to launch a recipe book which would be based on diets and recipes of food eaten locally. Diet control is essential element of diabetes control but it should be advised keeping in view the local norms, eating habits and needs of the people”, he added.

Dr. Zahid Miyan who is the Vice President of Diabetic Foot International (D-Foot Int.), deplored that data suggests 70 percent of the people whose legs are amputated due to diabetic foot ulcers, die within five years of the amputations as they acquire other diseases and ailments in addition to diabetes and its complications. He maintained that amputations and disability due to diabetic foot ulcers had become a global health concern and experts were coming with applicable and cost-effective solutions of this problem to reduce global burden of disability.

The message we want to convey today through this conference is that people with diabetes should take care of their feet more than their faces and try to prevent their feet from injury. One of the best ways to avoid injuries and foot ulcers is use of customized footwear, which helps in preventing amputations, he added.

Prof. Ejaz Vohra, Dr. Usman Faheem, Ms Erum Ghafoor, Salma Meher from United Kingdom, renowned nutritionist Saima Rasheed, Dr. Saif-ul-Haq and others also spoke during the FOOTCON 2019. Four workshops consisting screening Lab., infection control zone, handling the pressure and Use your skills on foot were also part of the FOOTCON 2019 besides free papers.