Mild to moderate claudication

Management is generally conservative, as in one-third of patients, symptoms resolve spontaneously.

Measures are aimed at preventing disease progression:

• exclude any associated condition e.g. diabetes mellitus, hyperlipidaemia, hypertension (1,2)
• encourage the patient to stop smoking and / or lose weight as appropriate and / or manage hyperlipidaemia
• encourage regular exercise to open and develop the collateral circulation. Exercise tolerance may be improved by using a walking stick and walking more slowly
  • regular exercise should be encouraged in all patients with intermittent claudication to increase walking distance and improve general cardiovascular health. Studies have demonstrated that exercise therapy is most effective when provided as part of a structured, supervised programme (3)
    
    
  • offer a supervised exercise programme to all people with intermittent claudication (10)
    • involves:
      • 2 hours of supervised exercise a week for a 3-month period
      • encouraging people to exercise to the point of maximal pain
        
        
• emphasize the need to take great care not to injure the leg since healing is generally poor
  
  
• drug therapy:
  • anti-platelet drugs such as aspirin 75 mg per day, may, long-term, improve outcome
  • address other cardiovascular risk factors:
    • lipid lowering treatment - consider patients as secondary prevention (there cardiovascular risk does not need to be calculated)
      • target lipid values are total cholesterol < 4mmol/ and LDL cholesterol < 2mmol/l (1)
    • hypertension - blood pressure lowering treatment is required if persistent blood pressure of more than 140/90 mmHg (2)
  • symptomatic treatment
    • a NICE review (3) has now stated that naftidrofuryl is the recommended treatment for patients with intermittent claudication:
      • naftidrofuryl 200mg tds daily may alleviate symptoms and improve pain-free walking distance in moderate disease
        • naftidrofuryl oxalate (10)
          • consider naftidrofuryl oxalate for treating people with intermittent claudication only when:
            • supervised exercise has not led to satisfactory improvement and
            • the person prefers not to be referred for consideration of angioplasty or bypass surgery
          • review progress after 3-6 months and discontinue naftidrofuryl oxalate if there has been no symptomatic benefit
            
      • cilostazol is an alternative treatment although not recommended by NICE
        • a phosphodiesterase inhibitor
        • licensed for use in intermittent claudication to improve walking distance in patients without peripheral tissue necrosis and who do not have pain at rest (4)
        • cilostazol (100 mg twice daily) has been shown to improve maximal walking distance by 40% to 50% in patients with peripheral vascular disease (5)
      • other alternative therapies not recommended by NICE for the treatment of intermittent claudication were pentoxifylline and inositol nicotinate (3)
      • cilostazol (11)
        • should not be given to:
          • patients taking two or more additional antiplatelet/anticoagulant medications
          • patients with unstable angina, or who have had myocardial infarction/coronary intervention in the last 6 months
          • patients with a history of severe tachyarrhythmia
        • a reduction of dose to50mg bd is appropriate in certain situations e.g. where patients are being treated with other medicines that are strong inhibitors of CYP3A4 or CYP2C19
          
          
• follow-up patients regularly
  
  
• NICE suggest consideration for angioplasty or bypass surgery should be the next step in management if supervised exercise has not led to a satisfactory improvement in intermittent claudication
  • angioplasty and stenting
    • should be offered if intermittent claudication only when:
      • advice on the benefits of modifying risk factors has been reinforced and
      • a supervised exercise programme has not led to a satisfactory improvement in symptoms and
      • imaging has confirmed that angioplasty is suitable for the person
  • primary stent placement should not be offered for treating people with intermittent claudication caused by aorto-iliac disease (except complete occlusion) or femoro-popliteal disease
  • primary stent placement should be considered for treating people with intermittent claudication caused by complete aorto-iliac occlusion (rather than stenosis)
  • bare metal stents should be used when stenting is used for treating people with intermittent claudication
  • bypass surgery and graft types
  • bypass surgery should be offered if severe lifestyle-limiting intermittent claudication only when:
    • angioplasty has been unsuccessful or is unsuitable and
    • imaging has confirmed that bypass surgery is appropriate for the person
  • use an autologous vein whenever possible for people with intermittent claudication having infra-inguinal bypass surgery

Notes:

• there is some evidence that ramipril improves walking ability in patients with peripheral vascular disease (6)
• if diabetic then optimal target for glycaemic control in diabetes is a fasting or pre-prandial glucose value of 4.0-6.0 mmol/l and a HbA1c < 6.5% (1)
• addition of oral anticoagulation to antiplatelet therapy does not reduce CVD events in patients with PVD (7)
• buflomedil is an alpha1-, alpha2-adrenolytic agent with vasoactive and haemorheologic properties
  • compared with placebo, it appears to improve the walking ability of patients with intermittent claudication (8)
  • compared with placebo, buflomedil administered for 3 years reduced the occurrence of symptomatic cardiovascular events by 26% (8)
• clopidogrel is recommended as an option to prevent occlusive vascular events for people who have peripheral arterial disease (9)

Reference:

• (1) JBS2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005; 91 (Supp 5).
• (2) NICE (June 2006). Hypertension - management of hypertension in adults in primary care.
• (3) NICE (May 2011). Cilostazol, naftidrofuryl oxalate, pentoxifylline and inositol nicotinate for the treatment of intermittent claudication in people with peripheral arterial disease
• (4) BNF 2.6.4
• (5) Dawson DL et al. Cilostazol has beneficial effects in the treatment of intermittent claudication. Circulation 1998;98: 678-686.
• (6) Ahimastos AA et al. Brief communication: ramipril markedly improves walking ability in patients with peripheral arterial disease: a randomized trial.Ann Intern Med 2006;144:660-4
• (7) Warfarin Antiplatelet Vascular Evaluation Trial Investigators, Anand S et al. Oral anticoagulant and antiplatelet therapy and peripheral arterial disease.N Engl J Med. 2007 Jul 19;357(3):217-27
• (8) Limbs International Medicinal Buflomedil (LIMB) Study Group, Leizorovicz A, Becker F. Oral buflomedil in the prevention of cardiovascular events in patients with peripheral arterial obstructive disease: a randomized, placebo-controlled, 4-year study. Circulation. 2008 Feb 12;117(6):816-22.
• (9) NICE (December 2010).Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events
• (10) NICE (March 2018). Lower limb peripheral arterial disease: diagnosis and management
• (11) Otsuka (May 1st 2013). Direct Healthcare Professional Communication on new safety information for Pletal (R) (cilostazol)