Understanding The Dangers Of PVD And PAD

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Author(s): 
By Khurram Khan

As physicians, we should raise questions about the patient’s control of these different risk factors. Results from multiple studies, including the Diabetes Control and Complications Trial (DCCT), showed an average weight loss of seven pounds (or 5 to 10 percent of body weight) improves diabetes control, decreases insulin resistance, decreases hepatic glucose production, and increases insulin secretion. There is much for the patient to gain from this knowledge, but it is up to us to process this information and deliver it in a way that can be understood.
What About Trental And Pletal?
There are several pharmacological agents you can use to treat intermittent claudication. Generally, you would combine these agents with diet, exercise and nutritional balancing measures. Trental (pentoxifylline) and Pletal (cilostazol) have both been shown to reduce the pain associated with intermittent claudication and allow patients to increase walking distance.
Trental works at the level of the cell membrane in which red blood cells are made more pliable, thus allowing them to move through the vascular tree with less resistance. Pletal has many different pharmacological effects which combine to improve blood flow.
The principal pharmacologic effects of Pletal are vasodilatation, reversible inhibition of platelet aggregation and increased cyclic AMP. In fact, a 12-week, multicenter, randomized, double-blind trial of Pletal noted the following effects:
• inhibits thrombus formation;
• produces vasodilatation;
• increases blood flow;
• increases HDL-cholesterol by 10 percent;
• decreases triglycerides by 15 percent; and
• inhibits (in vitro) vascular smooth muscle cell proliferation.10-11
Final Notes
In conclusion, intermittent claudication and peripheral vascular disease are highly prevalent manifestations of atherosclerosis and are associated with high risk for a multitude of illnesses and even death. Unfortunately, many practitioners underestimate the impact of peripheral arterial disease and the importance of its proper diagnosis and treatment. We should be aggressive in regards to PAD and the need for the patient to have a full workup by their primary care physician to control the modifiable risk factors — including diet, exercise and smoking.
We should also institute a supervised walking program and use the available pharmacologic agents to help patients walk longer. Finally, we should be more vigilant in our efforts to help patients reach their goals of pain-free ambulation, as we may very well be saving their lives.
Dr. Steinberg (pictured) is an Assistant Professor in the Department of Orthopaedics / Podiatry Service at the University of Texas Health Science Center. He is also the Medical Director of the Texas Diabetes Institute Podiatry Clinic.
Mr. Khan is a first-year resident at the University of Texas Health Science Center in San Antonio.




References:

References
1. Mokdad et al. the continuing epidemics of obesity and diabetes in the US. JAMA.2001;286:1195-1200.
2. Gersh et al. Ann Surg 1984.
3. Harrison Internal Medicine 3rd edition.
4. Brand FN et al. diabetes, intermittent claudication and risk of cardiovascular events. The Framingham study. Diabetes 38:504-509; 1989.
5. Haffner SM et al. N Eng J Med. 1998; 339: 229.
6. ADA-Diabetes Care 1996; 5196-5102.
7. Grundy SM et al, diabetes care 1990 153-160.
8. Lancet 1994; 344:1383-1389.
9. Hirsch et al. the role of tobacco cessation, antiplatelet and lipid lowering therapies in the treatment of peripheral vascular disease. Vasc Med 2:243-251;1997.
10. FDA Advisory Committee meeting Dossier: cilostazol for use in patients with intermittent claudication. Otsuka America Pharmaceutical, Inc. Rockville, MD; 6/3/1998.
11. Elam et al, effect of the novel antiplatelet agent cilostazol on plasma lipoproteins in patients with intermediate claudication. Arterioscler Thromb Vasc Biol 18:1942-1947;1998.

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