Peripheral Arterial Occlusive Disease Medication

Daily aspirin is recommended for overall cardiovascular care. While standard dosages range from 81-325 mg/d, no consensus has been reached on the most effective dose.

Pentoxifylline (Trental) shows promise. Numerous randomized trials have documented modest improvements in walking distance when compared with placebo treatment groups. Treatment can take 2-3 months to produce noticeable results.

The use of clopidogrel bisulfate (Plavix) and enoxaparin sodium (Lovenox) in the treatment of this entity is increasing; however, further research is needed to establish clinical efficacy.

Cilostazol (Pletal) has recently shown increasing promise in the treatment of intermittent claudication. Several randomized studies have shown benefits in increasing walking distances for both the distance before the onset of claudication pain and the distance before exercise-limiting symptoms become intolerable (ie, maximal walking distance).

In a randomized, double-blind, placebo-controlled trial, O’Donnell et al assessed the vascular and biochemical effects of cilostazol therapy in individuals (n=80) with peripheral arterial disease. Arterial compliance, transcutaneous oxygenation, ankle-brachial index, and treadmill walking distance were measured. The cilostazol group had significant reduction in the augmentation index and also showed reduction in transcutaneous oxygenation levels compared with the placebo group. Mean percentage change in walking distance improved more in the cilostazol group from baseline compared with the placebo group. Lipid profiles were also improved in the cilostazol group. The results showed that cilostazol is an efficacious treatment of peripheral arterial disease. In addition to improving patients’ symptoms and quality of life, cilostazol also appeared to have beneficial effects on arterial compliance.^[5]

In 2009, Momsen et al evaluated the efficacy of drug therapy in improving walking distance in intermittent claudication.^[6] Their study determined that statins seemed to be the best in improving maximal walking distance.

Cholesterol-lowering statin agents are beneficial in the medical therapy for peripheral arterial disease.^[7] In addition to effectively lowering blood cholesterol profiles, recent evidence from the Heart Protection Study showed that cholesterol-lowering statin agents (simvastatin) reduced the rate of first major vascular events (myocardial infarction, stroke, or limb revascularization), with the largest benefits seen in patients with peripheral vascular disease.^[8]

The benefits were demonstrated regardless of the baseline cholesterol profile. As such, cholesterol-lowering statin agents should be considered for medical treatment in patients with peripheral arterial disease.

Class Summary

Decrease overall risk of cardiovascular disease from myocardial infarction and stroke. Also improve walking distance by enhancing circulation.

Aspirin (Anacin, Ascriptin, Bayer aspirin)

Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2.

Clopidogrel (Plavix)

Selectively inhibits ADP binding to platelet receptor and subsequent ADP-mediated activation of glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation. Indicated for reduction of atherosclerotic events.

Cilostazol (Pletal)

Mechanism of effects on symptoms of intermittent claudication not fully understood. Cilostazol and several of its metabolites are PDE III inhibitors, inhibiting phosphodiesterase activity and suppressing cAMP degradation, with a resultant increase in cAMP in platelets and blood vessels, leading to inhibition of platelet aggregation and vasodilation, respectively. Reversibly inhibits platelet aggregation induced by various stimuli, including thrombin, ADP, collagen, arachidonic acid, epinephrine, and shear stress.

Pentoxifylline (Trental)

Indicated for treatment of patients with intermittent claudication due to atherosclerosis or other obstructive arteriopathies. Improves blood flow by increasing red blood cell deformability, which decreases viscosity of blood.

Class Summary

These agents are beneficial in lowering blood cholesterol profiles, which may reduce the rate of first major vascular events.

Simvastatin (Zocor)

Reduces cardiovascular heart disease mortality and morbidity (eg, nonfatal myocardial infarction or stroke, revascularization procedures) in high-risk patients (ie, existing coronary heart disease, diabetes, peripheral vessel disease, history of stroke or other cerebrovascular disease). Competitively inhibits HMG-CoA, which catalyzes the rate-limiting step in cholesterol synthesis. Patients should be placed on a cholesterol-lowering diet; the diet should be continued indefinitely.