What medications are used to treat chronic venous insufficiency (CVI)?

Medications for Chronic Venous Insufficiency

Compression therapy is the mainstay of treatment for chronic venous insufficiency (CVI), while pharmacological options like diosmin can provide additional symptomatic relief. 1

First-Line Treatment: Compression Therapy

Compression therapy is widely recognized as the primary conservative treatment for CVI and should be implemented before or alongside pharmacological interventions:

• Recommended pressure levels:

  • Minimum pressure of 20-30 mmHg for mild to moderate CVI
  • Higher pressures of 30-40 mmHg for more severe disease 1

• Types of compression:

  • Compression stockings (most common)
  • Compression bandages
  • Compression pumps

• Application considerations:

  • Higher pressure at the calf compared to distal ankle (negative graduated compression) provides better ejection fraction in refluxing vessels 1
  • Proper fitting and patient education are essential for adherence

Pharmacological Options

Flavonoids

1. Diosmin (Vasculera/Diosmiplex):

   • FDA-approved medical food for CVI management
   • Dosage: 600 mg daily for general CVI manifestations 2
   • For hemorrhoidal disease: 1 tablet 3 times daily for 4 days, then 1 tablet twice daily for 9 days, followed by maintenance dose of 600 mg daily 2
   • Mechanism: Manages venous inflammation, reduces accumulation of leukocytes and platelets, and decreases edema 2
   • Adverse effects: Generally mild, including gastrointestinal disturbances (7%) and headaches 2

2. Other flavonoids:

   • Horse chestnut seed extract (aescin) has shown short-term improvement in CVI signs and symptoms 3
   • Troxerutin has demonstrated potential benefits in regularizing venous tone 4
   • Note: Most flavonoid supplements are not FDA-approved medications 5

Treatment Algorithm Based on CVI Severity

Mild CVI (C1-C2: telangiectasias, reticular veins, varicose veins)

1. Compression stockings (20-30 mmHg)
2. Consider diosmin 600 mg daily if symptoms persist

Moderate CVI (C3-C4: edema, skin changes)

1. Compression stockings (30-40 mmHg)
2. Diosmin 600 mg daily
3. Consider referral to vascular specialist if symptoms are not adequately controlled

Severe CVI (C5-C6: healed or active venous ulcers)

1. Compression therapy (30-40 mmHg)
2. Diosmin 600 mg daily
3. Appropriate wound care for ulcers
4. Referral to vascular specialist for consideration of interventional therapies 5

Important Considerations and Pitfalls

• Compression therapy limitations:

  • Despite being first-line treatment, patient adherence is often poor
  • Evaluate for arterial disease before prescribing compression (16% of patients with venous ulcers have concomitant arterial occlusive disease) 1

• Pharmacological therapy caveats:

  • Results with diosmin may not be seen for 4-8 weeks, and for venous ulcers, results may take several months 2
  • Diuretics and topical steroid creams may provide short-term relief but offer no long-term treatment advantage 3

• When to refer:

  • Patients with more severe manifestations of CVI should be referred to a vascular subspecialist for consideration of interventional therapies 5
  • Interventional options include endovenous thermal ablation, ultrasound-guided foam sclerotherapy, and surgical approaches for patients with significant reflux 6

By implementing this treatment approach, focusing on compression therapy as the foundation and adding appropriate pharmacological management, most patients with CVI can achieve significant symptom improvement and prevention of disease progression.