| Do You Have Peripheral Arterial Disease? |
Peripheral arterial disease (PAD) affects 8 to 12 million people in the US.1 PAD is a condition where blood vessels that carry blood to the legs become clogged. They become clogged due to atherosclerosis, a condition where plaques form on the walls of these vessels. Older age, diabetes, high cholesterol, high blood pressure and smoking are all risk factors for PAD. Patients with PAD may experience pain in their legs when walking. This is referred to as ‘intermittent claudication’. This can cause many people with PAD to have trouble tolerating walking or exercising. More serious complications include the starvation of the tissue in the lower limb which can result in amputation.
Treatment for PAD has traditionally focused on reducing pain and modifying risk factors such as high blood pressure and coronary heart disease. If you have been diagnosed with PAD the following is a summary of the core areas that you and your doctor will focus on during your treatment.
Modifying your risk factors for coronary artery disease (CAD) is an important part of your PAD therapy because 25% to 35% of patients with PAD will suffer either a stroke or heart attack within five years. PAD is associated with a risk of heart attack and stroke because the buildup of plaques are likely to build up in the heart and vessels leading to the brain as well as in the legs. Let’s take a quick look at the different risk factors for CAD and how you and your doctor can work to prevent them.
High Cholesterol
High cholesterol or ‘hyperlipidemia’ will be a major target for treatment for you and your doctor. Studies have shown that aggressively treating hyperlipidemia in PAD patients reduces cardiovascular problems.2 A group of drugs called ‘statins’ are the drugs of choice for lowering cholesterol in patients with PAD. Some of these statins are also showing promising results in treating the PAD itself, although more research is needed. Examples of statins include:
· Mevacor (Lovastatin)
· Pravachol (Pravastatin)
· Lescol (Fluvastatin)
· Lipitor (Atrovastatin)
· Baycol (cerivastatin)
These medications can lower
High Blood Pressure
High blood pressure is a risk factor for both CAD and PAD. Patients with PAD should aim for a blood pressure target of 130/80. Traditional medications that are used in other patients to treat high blood pressure can be used in patients with PAD. In the past, a group of medications called beta-blockers have been avoided in PAD patients because of thoughts that they may worsen symptoms. Now, it is recognized that beta blockers may help decrease the risk of CAD in patients with PAD and that symptoms are not increased by their use.
ACE inhibitors are another class of medications for high blood pressure. These medications are good to use in patients with PAD. In fact, one drug in particular, ramipril (Altace) was shown to reduce cardiovascular problems in
Diabetes
Diabetes is also a risk factor for CAD and PAD. It is especially important to manage your blood sugar if you have PAD because the blockage of the small blood vessels are associated with all kinds of problems, particularly when you are diabetic. Diabetics are even more susceptible to blood vessel blockages. These blockages can lead to problems such as blindness, diabetic neuropathy and can lead to the amputation of limbs. It is very important, especially if you have PAD, to maintain a HgA1C of 7% or less. The HgA1C (hemoglobin A1C) is a measurement of how high, on average, your blood sugar has been over the last 3 months.
Smoking Cessation
I know, I know….if you smoke, you are probably tired of people trying to get you to quit, however, you should know that smoking is a major risk factor for CAD and PAD. Smoking is also associated with an increased risk of amputation.4
Treating the Symptoms of PAD Now that we have covered some of the ways we can modify our risk factors like high blood pressure, high cholesterol and smoking, we can move on to methods that are used to treat the symptoms of PAD.
Exercise
Exercise has been shown to increase walking distance 110% to 150%.2 This is a much greater improvement than that which is seen with some of the drugs we use to treat intermittent claudication like Trental and Pletal. Make sure to talk to your doctor before starting an exercise regimen.
This drug helps dilate the blood vessels and helps keep the blood cells from sticking together to form clots. This can help the vessels in the legs from being blocked and can improve the symptoms of intermittent claudication. Data shows that it has better symptom relief and shows more improvement in quality of life than Trental.2,3 This drug should not be used if you have heart failure.
Trental (pentoxifylline) This medication changes the flexibility of the blood cells and actually has the effect of ‘thinning’ the blood. This medication is approved for the treatment of intermittent claudication. Even though it is approved for this symptom, studies that show its effectiveness are mixed and studies in favor of the drug have shown only modest effects at best.2,3 For this reason, it is typically reserved for patients who have severe PAD who have not improved using exercise or Pletal.
Surgery
Surgery is sometimes used in those patients who have severe blood vessel blockages. These patients might suffer from pain, even at rest or may have ulcers present from the lack of blood flow or may be in danger of losing the limb. In many cases, an unblocking of the vessel can be accomplished and the blood flow can be restored.
Other Medications
Aspirin and Plavix (clopidogrel) are two medications that are sometimes used in patients with PAD. These medications help keep the blood from clotting. There is less evidence to support the use of these drugs in patients with PAD.2,4 Even though the data is limited, most experts recommend aspirin 81 to 325mg daily be started in patients with PAD. Patients who are not able to tolerate aspirin may try Plavix. Data does show that Plavix reduced the risk of ischemic events (events where vessels were blocked) more so than aspirin, although affects were somewhat modest. Research continues to try to find out what role these medications have in PAD.
Treatment in General
Keeping your risk factors (high blood pressure, high cholesterol, smoking and diabetes) under control is extremely important when you have PAD. In addition to risk factor control, most patients will find treatment with exercise and Pletal will be the most effective. Throughout the treatment process, make sure to keep the lines of communication with your doctor open. The best treatment plan will be the one that you and your doctor come up with together.
Author: Christi Larson, Pharm. D. Dr. Larson is a Clinical Infusion Pharmacist, author of Empowered Medicine; A Guide for Consumers and creator of www.empoweredmedicine.com. You can read more about her by visiting www.EmpoweredMedicine.com and clicking on the 'About Us' tab. EmpoweredMedicine.com is committed to providing evidence-based medical information.
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