What medications are used to treat intestinal angina?

Medications for Intestinal Angina

Calcium channel blockers, particularly dihydropyridines, are the first-line pharmacological therapy for intestinal angina, with doses up to 120 mg/day of nifedipine recommended for chronic management. 1

Pathophysiology and Medication Selection

Intestinal angina results from inadequate blood flow to the intestines, typically due to atherosclerotic stenosis or vasospasm of the mesenteric arteries. The primary goal of pharmacological therapy is to improve mesenteric blood flow.

First-line Medications:

1. Calcium Channel Blockers (CCBs)

   • Preferred agents: Dihydropyridine CCBs (e.g., nifedipine)
   • Mechanism: Vasodilation of splanchnic vessels, reducing vasospasm
   • Dosing: Up to 120 mg/day of nifedipine for chronic management 1
   • Monitoring: Watch for hypotension, headache, dizziness, flushing, and leg edema

2. Nitrates

   • Can be used as add-on therapy for refractory cases 2
   • Short-acting nitrates provide immediate relief of anginal symptoms 2
   • Long-acting nitrates can be considered for chronic management 1
   • Contraindicated in patients with hypertrophic cardiomyopathy or when co-administered with phosphodiesterase inhibitors 2

Combination Therapy Approach

For patients with inadequate symptom control on monotherapy:

1. Initial therapy: Start with a calcium channel blocker (preferably dihydropyridine)
2. Add-on therapy: If symptoms persist, add long-acting nitrates 2, 1
3. Alternative options: Consider ranolazine, nicorandil, or trimetazidine for patients with intolerance or contraindications to CCBs 2

Important Medication Considerations

• Drug interactions: Do not combine non-dihydropyridine CCBs (verapamil, diltiazem) with ivabradine due to risk of severe bradycardia 2, 1
• Antiplatelet therapy: Low-dose aspirin (75-100 mg daily) may be considered in patients with atherosclerotic disease 2
• Anticoagulation: May be necessary in patients with significant vascular compromise or history of thromboembolism

Beyond Pharmacological Management

While medications are important for symptom management, definitive treatment often requires revascularization:

• Endovascular interventions: Percutaneous endovascular treatment is indicated for patients with chronic intestinal ischemia 2
• Transcatheter vasodilator therapy: Direct administration of vasodilators into areas of vasospasm can be effective 2, 1
• Surgical revascularization: May be necessary for severe cases with extensive vascular involvement

Monitoring and Follow-up

• Regular assessment of symptom relief (particularly postprandial pain)
• Monitoring for medication side effects
• Weight monitoring (weight loss is a concerning sign of inadequate treatment)
• Consider repeat vascular imaging to assess treatment efficacy in patients with persistent symptoms

Pitfalls to Avoid

• Delaying diagnosis and treatment can lead to intestinal infarction
• Overlooking the need for comprehensive vascular assessment (at least two major vessels typically need significant stenosis to cause symptoms)
• Failing to consider revascularization when pharmacological management is inadequate
• Using non-dihydropyridine CCBs with ivabradine (dangerous drug interaction)

Remember that while medications can help manage symptoms, they do not address the underlying vascular stenosis that often requires interventional or surgical management for definitive treatment.