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Introduction

Diabetic Foot Ulcers (DFUs) affect around 18.6 million patients annually. The global prevalence of this condition stands at 6.3%.^1,2 Lifetime risk for foot ulcers varies between 19 and 34%. Recurrence rates of DFUs can be as high as 65% in three to five years.³ DFUs are more common in males and Type 2 diabetic patients, while Type 1 diabetes has a lesser severity of DFUs. The highest prevalence is in North America at 13% and Oceania has the lowest prevalence at 3%.¹ These ulcers precede 80% of lower extremity amputations in diabetic patients, and a five-year mortality rate among the individuals with DFUs is about 30%, rising to more than 70% in patients with major amputations.² The mortality rate is higher in DFU patients, 231 deaths per 1000 person-years, compared to 182 diabetic patients without DFUs.² Cardiovascular disease and infection are the common causes of death among DFU patients.⁴ DFUs are a serious complication of diabetes with significant morbidity and mortality effects.^5,6 They are the leading cause of morbidity for diabetic patients and are associated with a higher risk for amputation, as well as with worse outcomes, especially major amputations.⁷ Managing DFUs is challenging and resource-intensive, being best accomplished using multidisciplinary coordinated care delivered by physicians, nurses and foot care specialists.⁵ The burdens of healthcare in standard care interventions are pressure off-loading, sharp debridement, wound moisture balance, infection control and management of peripheral arterial disease.⁸ However, at the end of 12 months of treatment, only 45% of patients survive, have no ulcers and also have no amputation.⁹

DFUs and cardiovascular diseases (CVDs) share overlapping risk factors and pathophysiological mechanisms, including old age, male gender and uncontrolled glycemia with high HbA1c levels.^1,2 Hyperglycemia disrupts wound healing, immune function and vascular health. Autonomic neuropathy further complicates the cardiovascular system, leading to increased mortality. Common biomarkers for DFUs and CVDs include HbA1c, creatinine, low-density lipoprotein (LDL), and HDL, representing the cardio-renal-metabolic-foot connection.¹⁰ Patients with DFUs face elevated cardiovascular risks, with a relative risk of 1.25 for ischemic heart disease, 2.03 for cerebrovascular accidents and 2.59 for all-cause cardiovascular mortality. Prevalence rates among DFU patients include 37.1% for all-cause cardiovascular morbidity, 44.7% for ischemic heart disease, 25.1% for congestive heart failure, and 10.9% for cerebrovascular accidents.¹¹ High inflammatory markers like IL-6 and resistin exacerbate these risks, forming a bidirectional relationship between DFUs and CVDs. Pharmacists, with their accessible and versatile skill set, play a critical role in DFU management. They offer regular foot examinations, monitor loss of protective sensation (LOPS), support metabolic control and recommend specialty foot care services.¹² Pharmacists also guide antibiotic therapy based on culture results, enabling effective infection control. Their frequent interactions during prescription refills facilitate early problem detection, timely interventions and appropriate referrals, positioning them as key members of multidisciplinary diabetes care teams. Furthermore, pharmacists address gaps in health literacy, preventive care and treatment adherence. They educate patients on foot care and medication management, assist with insurance and supply access and improve adherence to Infectious Diseases Society of America (IDSA) guidelines.¹³ Through these contributions, pharmacists help monitor wound progression and enhance patient outcomes. This review discusses existing challenges, research gaps and the expanding role of pharmacists in the management of DFUs through highlighting the clinical and cardiovascular impacts of pharmacist-led interventions.

Methodology

This narrative review summarised evidence on pharmacist-led or pharmacist-integrated strategies for managing diabetic foot ulcer(s) (DFU[s]) and their cardiovascular impacts. We searched PubMed/MEDLINE, Scopus and Web of Science for English-language studies published 1 January 2000 to 31 December 2023, combining controlled vocabulary (MeSH) and free-text terms with Boolean operators; an example PubMed query was: (“Diabetic Foot”[MeSH] OR diabetic foot ulcer* OR DFU OR DFUs) AND (Pharmacists[MeSH] OR pharmacist* OR “medication therapy management” OR “antimicrobial stewardship”) AND (cardiovascular OR CVD OR hypertension OR dyslipidemia OR HbA1c). Given the narrative design and heterogeneity across populations, interventions, comparators, outcomes and follow-up, no meta-analysis or quantitative pooling was undertaken; effect estimates are reported as published. Inclusion criteria encompassed peer-reviewed studies discussing pharmacist interventions, such as antimicrobial therapy, patient education and advanced wound care, with clinical or cardiovascular outcomes. Non-peer-reviewed articles, case reports, and studies with poor methodological rigor were excluded. Data extraction captured study design, population, interventions and outcomes, including sample sizes (n), effect estimates with 95% confidence intervals (95% CIs), and whether risk reductions were relative (RR/OR/HR) or absolute (ARR), which were synthesised thematically, covering pharmacological strategies, education and advanced care. In addition, we extracted any available information on pharmacists’ training, credentials or scope of practice; however, this was infrequently and inconsistently reported across studies. The quality of included studies was assessed using Cochrane Risk of Bias tools (RoB 2 for randomised trials; ROBINS-I for non-randomised studies) and AMSTAR 2 for systematic reviews. No primary data collection was involved, eliminating the need for ethical approval. The review highlights gaps in current care models and emphasises the role of pharmacists in DFU management, although its narrative nature may introduce some bias due to study heterogeneity.

Results and discussion

Pathophysiology of diabetic foot ulcers

Diabetic foot ulcers result from the interaction of a multiplicity of pathophysiological mechanisms initiated by chronic hyperglycemia in diabetes mellitus.⁵ It is responsible for the series of vascular, neural and immune dysfunctions initiated by long-term exposure to elevated glucose levels. Hyperglycemia damages the peripheral nerves with resultant neuropathy. The feet therefore lose their protective sensation, and hence patients do not feel minor injuries or pressure points which eventually turn to wounds.¹⁴ Hyperglycemia further leads to vasculopathy, with the formation of atherosclerotic plaques and narrowing or blocking blood vessels, resulting in reduced blood flow to extremities leading to ischemia and deprivation of tissues for necessary oxygen and nutrients. The patient’s ability to heal wounds is significantly impaired in such a state.¹⁴ At the cellular level, chronic hyperglycemia triggers abnormal immune responses. Thus, macrophages that play such an important role in tissue repair become polarised towards the pro-inflammatory phenotype, M1 macrophages and release excess amounts of cytokines, chemokines and Reactive Oxygen Species (ROS), which result in a chronic inflammatory state degrading the Extracellular Matrix (ECM)  and disrupting the balance of growth factors and stromal cells necessary for healing.¹⁵ Thus, overactive production of Matrix Metalloproteinases (MMPs), like MMP-9, continues degrading ECM and slows the healing process. Besides this, hyperglycemia also impairs the function of fibroblasts, reducing collagen synthesis and the structural integrity of the wound bed. Moreover, it inhibits angiogenesis, the formation of new blood vessels. This leads to a hostile wound environment where tissue regeneration is slow and infection risk is high.¹⁶ (Figure 1).

 

Figure 1. Pathophysiology of diabetic foot ulcers from hyperglycaemia to tissue necrosis

 

Chronic hyperglycaemia in diabetes mellitus precipitates three interacting pathways peripheral arterial disease (PAD) with reduced blood flow and tissue hypoxia, peripheral neuropathy causing loss of protective sensation and nerve damage, and immune/inflammatory dysregulation (impaired leukocyte function, pro-inflammatory state, reduced growth-factor production). These mechanisms converge to produce fluid discharge (exudate), biofilm formation and infection (cellulitis/osteomyelitis), culminating in necrotic tissue.

Progression to severe outcomes

Without timely intervention, DFUs can progress rapidly from a superficial ulcer to severe complications, including infection, gangrene and the potential need for amputation.¹⁷ Once the skin barrier is breached, wounds in diabetic patients are particularly susceptible to infections due to impaired leukocyte function, reduced chemotaxis and diminished phagocytosis.¹⁸ This creates a favorable environment for polymicrobial infections, including antibiotic-resistant pathogens like methicillin-resistant Staphylococcus aureus (MRSA). Furthermore, PAD limits antibiotic penetration and immune cell delivery to the affected tissues, allowing infections to spread more aggressively. Chronic wounds may develop biofilms that resist conventional therapies, further complicating management. Left unchecked, these infections can escalate to gangrene, a necrotic condition characterised by tissue death due to ischemia and infection. In severe cases, sepsis and systemic inflammatory response syndrome (SIRS) can arise, necessitating urgent surgical interventions, including debridement or amputation.¹⁹ These outcomes are associated with a significant reduction in quality of life and a high mortality rate, highlighting the critical need for early and effective management strategies.

Clinical implications and advanced management strategies

Management of DFUs requires a multi-disciplinary approach, focusing on early detection, risk assessment and targeted interventions to prevent severe outcomes. Regular foot screening in diabetic patients detects neuropathic and ischemic changes before these conditions advance to ulceration.²⁰ Advanced wound care in addition to debridement, offloading techniques and the use of bioengineered skin substitutes also seems to promote healing. In addition, re-establishment of perfusion in ischemic limbs through vascular interventions, such as angioplasty or bypass surgery, can be very effective. New therapies to counteract damage caused by hyperglycemia, such as inhibitors of Advanced Glycation End-products (AGEs) formation or oxidative stress are being developed to correct the underlying molecular dysfunctions.²¹ Proper infection control is crucial and guided by culture-specific antibiotic regimens and, when appropriate by surgical debridement. Patient education about foot hygiene, appropriate footwear, and glycemic control further reinforces the prevention strategy. Such holistic strategies clearly point toward individualised care for alleviation of the DFUs’ burden and long-term outcomes.²² Pharmacists can target patients most likely to benefit — those with recurrent DFU, PAD/chronic kidney disease (CKD), suboptimal blood pressure (BP)/LDL-C/HbA1c, high antimicrobial exposure, or polypharmacy/non-adherence — where pharmacist-led optimisation and stewardship are most impactful and cost-effective. Pharmacists can implement DFU co-management via structured case-finding, antimicrobial stewardship and cardiometabolic treat-to-target protocols, supported by training in DFU assessment and PAD screening and enabled by collaborative practice agreements/protocols, shared Electronic Health Records (EHRs) documentation, tele-follow-ups and available reimbursement mechanisms.

Relationship between Diabetic Foot Ulcers (DFUs) and cardiovascular risk

Pathophysiological pathways

Due to the pathophysiological overlaps between the two conditions, including endothelial dysfunction, persistent systemic inflammation, and oxidative stress, the pathways shared between DFUs and CVDs are common.²³ The hyperglycemia-induced impairment of Nitric Oxide (NO)  synthesis due to endothelial dysfunction that leads to vasoconstriction, enhanced platelet aggregation, and pro-inflammatory conditions leaves patients vulnerable to peripheral artery disease (PAD), the common precursor to DFUs, and macrovascular complications, including Myocardial Infarction (MI). As many as 50% of people with diabetes who develop foot ulceration also have concomitant PAD, a condition that dramatically increases the risk for adverse limb outcomes and cardiovascular complications.²⁵ Another key relationship is systemic inflammation: DFUs are characterised by elevated levels of interleukins (IL-1, IL-6) and tumor necrosis factor-alpha (TNF-α), both of which are associated with impaired wound healing and accelerated atherosclerotic processes.²⁴ Additionally, oxidative stress, caused by AGEs and mitochondrial dysfunction, damages endothelial cells and promotes vascular remodelling. Researchers demonstrated increased markers of oxidative stress in patients with DFUs, which was associated with increased prevalence of coronary artery disease (CAD) and poor healing of the ulcers. These interrelated pathways create a vicious cycle, whereby microvascular complications like DFUs increase the risk of systemic macrovascular damage.

Clinical evidence

Several epidemiological and clinical studies have established the fact that DFUs are a risk factor for cardiovascular disease. A prospective study conducted by Qiu et al (2022)²⁵ demonstrated that the risk of cardiovascular death was at 2.5-fold increase in patients suffering from DFUs compared to diabetic patients without ulcers. Further, DFUs have lately been considered a marker of systemic atherosclerosis; studies by Barshes et al (2016)²⁶ have shown that SPPs or TBIs used uniformly or to support the findings of a normal pulse examination are among the most sensitive and cost-effective methods of identifying peripheral artery disease in patients with diabetic foot ulcers. This evidence underscores the systemic nature of DFUs and their role as a red flag for cardiovascular evaluation.

Current challenges in managing DFUs

The clinical challenges in the management of DFUs are massive in terms of late diagnosis, mismanagement and recurrence of ulcers. Most of the DFUs are undiagnosed in the early stages since most of these patients have no sensation due to peripheral neuropathy, which brings about reduced perception of pain. In this line, a study by Sk et al (2023)²⁷ has suggested that mycotic infections are seen in 23.3% of diabetic foot ulcers with Candida tropicalis being most common and are more often seen in patients having mild infections or ulcers persisting for 7–14 days.²⁷ Mismanagement is very common because inappropriate or late interventions take place frequently; that is, failure to debride the wound in due time, weak strategies for offloading the wound or infections not adequately controlled. The recurrence of DFUs is a significant issue; literature indicates that as many as 40% of the DFUs that are healed would recur within a year and as many as 60% within three years after healing. This often happens because of unresolved biomechanical abnormalities, continuous peripheral neuropathy or suboptimal control of glycemia.

Healthcare system barriers

Inefficiency in the delivery of healthcare forms a major basis for the less-than-adequate management of DFUs. Fragmented care, where multiple specialists are sought without a common care plan for the patient, delays treatment and compromises outcomes. According to Wennberg et al (2019)²⁸, most healthcare settings have limited access to podiatrists, vascular surgeons and infectious disease specialists, which leads to delayed or inappropriate referrals. The limited access to multidisciplinary teams in rural or underserved areas further worsens the disparities in care delivery. Moreover, healthcare systems focus on reactive rather than preventive strategies, thereby increasing the burden on tertiary care centers.

Economic and social implications

Economic burden is considerable in terms of both healthcare systems and on patients’ quality of life. DFU treatment is rather expensive because patients are constantly hospitalised and undergo surgery, sometimes with specialised care. A cost analysis by Jodheea-Jutton et al (2022) estimated the annual cost of DFU treatment in the US at $9–13 billion, in addition to the overall expenses associated with diabetes.²⁹ For individual patients, the financial strain of treatment often leads to poor adherence to prescribed therapies, contributing to ulcer recurrence or complications. Apart from the heavy economics, DFUs significantly affect the quality of life of patients, causing pain, restricting their mobility, and making them socially isolated. It has recently been reported that patients suffering from chronic DFUs are more prone to depression and anxiety as compared with other chronic diseases (Scott et al, 2023).³⁰ Such issues arise and there is the need for cost-effective interventions along with psychosocial support for patients with DFU.³⁰

Gaps in the current management models

The existing management models for DFUs have critical gaps that prevent effective treatment. Preventive care is underutilised, with low rates of foot screening and patient education on foot hygiene and injury prevention. A review by Alkhatieb et al (2023)³¹ reported that the rate of DFU recurrence was 27.8% among patients who used therapeutic footwear compared to 52.5% among patients who did not (p=0.013).³¹ Poor patient adherence to treatment regimens, including wound care, offloading devices and lifestyle modifications, is another major barrier. In the absence of integration of cardiovascular risk management into DFU care models, it is challenging to deal with systemic complications that worsen outcomes. Recent studies have shown that multidisciplinary approaches with cardiovascular specialists improve long-term outcomes by reducing both ulcer recurrence and cardiovascular mortality. However, these integrated models are rarely applied due to resource constraints and poor coordination between specialties.

Pharmacist-led interventions in DFU management

Patient education and counselling

One of the critical roles of the pharmacist when dealing with DFU is educating patients on diabetes care and foot hygiene. Holistic diabetic education programs will consist of teaching maintenance of adequate blood glucose levels, daily examination and checking for signs of infection or pressure points. For example, Bukhsh et al (2018)³² showed that pharmacist-led diabetes education significantly improved patients’ self-care behaviors, including proper footwear usage and foot inspections, which reduced the incidence of foot complications.³² Counselling sessions also enable patients to understand the significance of foot hygiene, such as washing, drying and moisturising their feet to prevent skin breakdown. Pharmacists can also provide tailored advice on avoiding harmful habits, such as walking barefoot, which exacerbates ulcer risks. Studies like Alshammari et al (2023)³³ highlight how such educational interventions can prevent the progression of minor foot injuries into ulcers, reducing hospital admissions.

Pharmacological interventions

Pharmacists play the key role within antimicrobial stewardship programs with respect to optimising topical and systemic antibiotics for managing DFU. They help advise on appropriate antibiotic choices based on available wound cultures thus preventing the selection of antibiotic-resistant species. For example, Li et al (2020)³⁴ highlighted that pharmacist-led interventions in antimicrobial therapy reduced overprescription but maximised clinical outcomes in DFU patients. Moreover, pharmacists also educate patients on the appropriate use of evidence-based topical treatments, including silver-impregnated dressings or honey-based products, which have been proven to be effective in healing wounds. An evidence-based review reported increased healing rates when pharmacists worked with wound care teams to adopt evidence-based treatment plans.

Improve diabetes control

Glycemic control is the backbone of preventing and managing DFU, and pharmacists have an important role in optimising an antidiabetic regimen. Starting or changing medication, including SGLT2 inhibitors and GLP1 receptor agonist, allows patients to reach target HbA1c levels. According to Ihekoronye et al (2024),³⁵ pharmacist-led interventions in diabetes medication management improve glycemic control, which directly relates to better wound healing and reduced ulcer recurrence. In addition, pharmacists deal with therapeutic inertia delays before elevating or altering treatment regimens for diabetes because they coordinate closely with physicians to prevent delays in interventions. In this respect, they also deal with adherence to medications by counselling patients on the need to continually take medications, as well as deterrents, such as costs or side effects.

Advanced wound care

Pharmacists are increasingly integrated into advanced wound care practices, including prescribing or directing the use of therapies like negative-pressure wound therapy (NPWT), which enhances wound healing by improving blood flow and reducing bacterial burden.³⁶ Gupta et al (2016)³⁶ demonstrated that NPWT was not superior to standard moist wound care (SMWC) in diabetic foot wounds in German clinical practice, where low wound closure rates and documentation deficits negatively impacted outcomes.³⁶ Furthermore, pharmacists collaborate with multidisciplinary teams of dietitians and wound care specialists to address all aspects. For instance, advanced therapies include growth factors such as platelet-derived growth factors and bioengineered tissues, which a pharmacist may recommend depending on individual patient needs.

Post-intervention monitoring

This role extends from the initial treatment to continuous monitoring of the wound’s progression and prevents recurrence. Digital health tools, for instance, include smartphone applications and wearable devices through which pharmacists may follow patients’ wound healing journeys and intervene early if there is a complication arising. Bolton et al (2016)³⁷ highlighted the role of telemedicine in the management of DFU by pharmacists, mentioning a 25% reduction in ulcer-related hospital admissions with the help of remote monitoring devices. In addition, pharmacists manage recurrent ulcers by developing long-term care plans that include regular foot checks, shoe prescription and lifestyle modifications. Follow-up studies showed lower recurrence rates for ulcers in patients whose pharmacists followed them up regularly for adherence to prevention strategies.³⁷

Effects of pharmacist-led interventions on cardiovascular risk management

Pharmacists are uniquely positioned to optimise cardiovascular pharmacotherapy. In lipid management, pharmacists ensure that patients are on appropriate statin therapy, addressing common barriers such as statin intolerance and non-adherence. Dixon et al (2020)³⁸ reported that pharmacist interventions significantly reduced LDL-C levels by -7.9mg/dL and improved total cholesterol, triglycerides, and high-density lipoprotein cholesterol. In cases where statins are contraindicated or insufficient, pharmacists facilitate the use of alternatives such as PCSK9 inhibitors or ezetimibe, ensuring comprehensive lipid control. In hypertension management, pharmacists leverage their expertise to select and titrate antihypertensive medications based on patient-specific factors, including comorbidities, drug interactions, and tolerability. Margolis et al (2020)³⁹ demonstrated that home blood pressure (BP) telemonitoring with pharmacist management lowered BP more than usual care for 24 months and may have reduced costs by avoiding cardiovascular events over 5 years. Pharmacists also play a crucial role in guiding the use of antiplatelet and anticoagulant therapies for secondary prevention. Studies reported improved adherence to dual antiplatelet therapy (DAPT) in patients managed by pharmacists, with significant reductions in bleeding complications due to regular monitoring and dose optimisation.

Clinical outcomes of pharmacist-led interventions

The care of pharmacists has been reported to dramatically enhance most cardiovascular biomarkers including glycated hemoglobin, lipid levels, BP and markers of systemic inflammation, including CRP and IL-6. For instance, Santschi et al (2014)⁴⁰ observed that pharmacist interventions were associated with greater reduction in systolic BP (β 7.6 mm Hg) and diastolic BP (β 3.9 mm Hg) compared to usual care. These improvements were attributed to the active involvement of pharmacists in individualised titration of medications, patient education and addressing adherence barriers.⁴⁰ Such interventions are particularly important for patients with DFUs, whose systemic inflammation and microvascular complications exacerbate cardiovascular risks. Apart from biomarker improvements, pharmacist-led care improves treatment adherence and patient engagement. For instance, Alfian et al (2020)⁴¹ reported that tailored pharmacist intervention based on personal adherence barriers may improve adherence to antihypertensive drugs among patients with Type 2 diabetes. Therapy adherence is critical for sustained cardiovascular risk reduction, especially In patients with chronic conditions, such as diabetes and DFUs. This, altogether, improves the long-term outcome on health by providing systematic approaches for interventions, which include follow-up, review of medication, and proactive management of side effects.

Table 1 summarises key studies evaluating pharmacist-led interventions, including sample size (n), duration of follow-up, and reported effect sizes. For continuous outcomes, results are presented as mean difference (MD), standardised mean difference (SMD), or weighted mean difference (WMD), each reported with corresponding 95% confidence intervals (CI). For dichotomous outcomes, effect estimates are expressed as risk ratios (RR), odds ratios (OR), or hazard ratios (HR), with 95% confidence intervals. In the RxEACH trial, the reported outcome reflects changes in estimated 10-year cardiovascular disease (CVD) risk rather than observed cardiovascular events. Absolute risk reduction (ARR) and number needed to treat (NNT) were not calculated.

 

Table 1. Studies on pharmacist-led interventions in cardiovascular risk management

 

Lifestyle and behavioural interventions

Beyond pharmacotherapy, pharmacists actively promote non-pharmacological strategies for cardiovascular risk reduction. Smoking cessation, a key modifiable risk factor, is effectively addressed through pharmacist-led counseling and nicotine replacement therapies. Community pharmacy personnel-driven smoking cessation interventions show a benefit compared to less intensive interventions (RR 2.30, 95% CI 1.33 to 3.97; I2=54%; low-certainty evidence). Similarly, pharmacist-led interventions in dietary counseling and physical activity promotion have been shown to improve patient adherence to lifestyle modifications. For instance, Kelly WN et al (2021)⁴⁹ reported that pharmacist medication counseling versus no counselling was associated with a statistically significant 30% increase in the likelihood of medication adherence (RR 1.30), a 24% relative reduction in 30-day hospital readmission (RR 0.76; number needed to treat=4.2), and a 30% relative reduction in emergency department visits (RR 0.70). Reductions in primary care visits and mortality were not statistically significant.⁴⁹

Barriers and challenges

Structural and systemic barriers

One of the primary barriers limiting the role of pharmacists in DFU and CVD management is the restricted prescribing authority in many regions. Pharmacists play a crucial role in managing patients with glycemic excursions through admission medication history, formulary management, individual patient medication management and interprofessional collaboration. Furthermore, variability in the scope of practice across regions contributes to inconsistencies in the effectiveness of pharmacist-led care. A meta-analysis by Tsuyuki et al (2016)⁴⁶ emphasised that expanded scopes of practice, including prescribing rights, led to improved outcomes in cardiovascular risk reduction. Additionally, training programs differ widely, with some focusing more on dispensing medications than on clinical interventions, as highlighted by dos Reis et al (2018).⁵⁰ This disparity in training undermines pharmacists’ readiness to address complex cases such as DFUs and CVDs effectively.⁵⁰ Across the included studies, the extent of pharmacist training was inconsistently reported. While some interventions clearly relied on pharmacists with additional expertise, such as training in antimicrobial stewardship, diabetes education or advanced wound care, many studies did not describe pharmacist qualifications in detail. Consequently, it remains uncertain whether the positive outcomes observed were achieved by pharmacists operating under routine practice or by those with enhanced clinical training or expanded prescribing authority. This has implications for scalability, because successful implementation in other settings may require structured training, certification pathways or collaborative practice agreements. The limited reporting of training requirements represents a methodological limitation of the current evidence and should be addressed in future research to clarify feasibility and implementation needs.

Resource and time constraints

Pharmacists frequently operate in high-demand environments where they balance dispensing duties, patient counselling and administrative responsibilities. This workload pressure significantly limits their capacity to engage in extended patient care activities. Obiedalla et al (2023)⁵¹ found that pharmacists spend 1–3 hours per week dealing with drug shortages, impacting workloads and patient care.⁵¹ Time constraints also limit pharmacists’ ability to provide follow-ups, which are essential for monitoring wound healing, adherence to therapies and cardiovascular risk markers. Brajković et al (2022)⁴⁴ documented improved cardiovascular outcomes when pharmacists had dedicated time for patient consultations, further underscoring the need for resource allocation to support their roles.

Future directions

Future work should test AI-assisted wound triage and image-based healing trajectories⁵², remote monitoring (such as smart insoles/thermography)⁵³ with pharmacist tele-management of home BP/glucose³, and supportive policy levers (training, reimbursement, collaborative practice agreements) to scale pharmacist-led DFU/CV care.

Conclusion

The management of DFUs poses significant clinical and systemic challenges due to their high recurrence rates, severe complications, and association with increased mortality. Pharmacist-led interventions have emerged as a transformative approach to DFU care, addressing critical gaps in current models. By leveraging their expertise in antimicrobial stewardship, glycemic control optimisation, patient education, and advanced wound care, pharmacists significantly improve outcomes for DFU patients. Clinical findings demonstrate reduced ulcer recurrence rates, improved wound healing and enhanced patient adherence through pharmacist-guided care plans. Notably, pharmacist-led interventions contribute to a 25% reduction in ulcer-related hospitalisations and optimise antibiotic therapy, minimising resistance risks while promoting effective infection control.

Beyond immediate clinical improvements, pharmacists play a pivotal role in mitigating cardiovascular risks associated with DFUs. Studies show a 22–27% reduction in cardiovascular mortality and hospitalisations due to pharmacist-led management of comorbidities like hypertension, dyslipidemia and systemic inflammation. These interventions also improve key biomarkers, including HbA1c and LDL-C levels, reinforcing the cardio-metabolic-foot connection in DFU management. Despite these advancements, systemic barriers, such as fragmented care and limited multidisciplinary access, persist. Expanding pharmacist integration into standardised, collaborative care frameworks is essential to bridging these gaps, offering a cost-effective and sustainable solution for reducing the burden of DFUs and improving patient quality of life.

Author contributions

Concept – Satheesh S, Praveena G
Literature Search – Satheesh S
Data Compilation and Synthesis – Satheesh S
Drafting of the Manuscript – Satheesh S
Critical Revision of the Manuscript – Praveena G
Supervision and Guidance – Praveena G
Final Approval of the Manuscript – Satheesh S, Praveena G

Conflict of interest

The authors declare no conflicts of interest

Ethics statement

No ethical approval was required for this study as it is a narrative review and did not involve the collection of primary data from human or animal subjects.

Funding

This review did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Author(s)

S Satheesh^1,2, G Praveena³*
¹Department of Pharmacy Practice, JKK Munirajah Institute of Health Sciences College of Pharmacy, Tamil Nadu, India
²Department of Pharmacy Practice, Karpagam Academy of Higher Education, Tamil Nadu, India
³Department of Pharmacognosy, Karpagam Academy of Higher Education, Tamil Nadu, India

*Corresponding author email praveena.g@kahedu.edu.in

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