An in-depth report on the causes, diagnosis, and treatment of peripheral artery disease (PAD).
Peripheral arterial disease; PAD; Peripheral vascular disease;
Treatments for PAD help manage leg pain and improve function, as well as reduce the risk for heart attack and stroke. Drugs used for improving leg pain and function are generally those that either prevent blood clots (typically antiplatelet drugs) or improve blood flow.
Antiplatelet drugs reduce the risk for blood clots. Most patients with peripheral artery disease should receive antiplatelet medication. For the most part, this recommendation is made to prevent future death from heart attack or stroke. Antiplatelet drugs may or may not provide benefit for PAD symptoms and progression.
Aspirin is usually the recommended first-line choice. Clopidogrel (Plavix) is recommended as an alternative.
Dipyridamole (Persantine) may help prevent complications of PAD when taken along with aspirin. Studies are mixed on the benefits of the combination. Without aspirin, the drug does not appear to have any advantages for patients with PAD.
Research indicates that adding an anticoagulant drug, such as warfarin (Coumadin), to antiplatelet therapy does not help prevent heart complications of PAD, and can increase the risks for life-threatening bleeding.
[For more information on these drugs, see In-Depth Report #03: Coronary artery disease.]
Phosphodiesterase inhibitors are drugs that help improve blood flow.
Cilostazol. Cilostazol (Pletal) is used to treat disabling intermittent claudication. A number of studies have reported that the drug helps improve walking distance and quality of life. It also helps improve HDL and triglyceride levels. Cilostazol works better than pentoxifylline, the first drug approved for claudication. It is expensive, however, and currently recommended only for patients with moderate-to-severe intermittent claudication who do not respond to aspirin or less costly treatments. Common side effects include headache, swelling in the limbs, and stomach problems such as diarrhea and flatulence (gas). It does not appear to have bad effects on the liver or kidney. Similar drugs have had serious side effects in patients with heart failure, so these patients should avoid cilostazol.
Pentoxifylline. Pentoxifylline (Trental) reduces the sticky properties of blood, improving its flow. It is approved in the U.S. for managing claudication, although doctors do not recommend its routine use. Studies regarding the drug's effectiveness have been mixed. Some studies have reported a small effect on walking ability; another found the drug significantly improved walking distance. Other research has found that the drug does not work any better than a dummy pill (placebo). The most common side effects include headache, nausea, heartburn, flatulence (gas), dizziness, blurred vision, and flushing.
Alteplase (Activase), also called t-PA, and reteplase (Retavase) are thrombolytic drugs. Such drugs are commonly called "clot-busters." They break up existing clots, and may be used in cases of acute vascular occlusion (the sudden development of a blood clot). They may also be used if a clot is present. Researchers are investigating whether thrombolytics are an effective alternative to surgery in severe cases of PAD. In severe cases, the drugs can be delivered directly into the artery.
ACE Inhibitors. ACE inhibitors are a type of drug used to treat high blood pressure. The ACE inhibitor ramipril (Altace) is often recommended for patients with symptomatic peripheral artery disease, primarily to reduce the risk of cardiovascular events.
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