What is the most appropriate medication for a patient with intermittent claudication due to peripheral artery disease (PAD) with an ankle-brachial index (ABI) of 0.70?

Cilostazol is the Most Appropriate Medication for Intermittent Claudication in PAD

Cilostazol (100 mg twice daily) is the most appropriate medication for this patient with intermittent claudication and an ABI of 0.70, as it is the only FDA-approved medication that consistently demonstrates significant improvement in walking distance and symptoms. 1

Diagnosis and Clinical Assessment

• The patient's presentation is classic for intermittent claudication:
  • Cramping and fatigue in calves and feet with walking
  • Symptoms resolve with rest (within 10 minutes)
  • ABI of 0.70 confirms moderate peripheral artery disease (PAD)

Treatment Algorithm for Intermittent Claudication in PAD

First-Line Therapy

1. Cilostazol 100 mg twice daily

   • Improves maximal walking distance by 40-60% after 12-24 weeks 1
   • Class I recommendation (Level of Evidence: A) from ACC/AHA guidelines 1
   • Mechanism: Phosphodiesterase type 3 inhibitor with vasodilator and antiplatelet properties 2
   • Should be taken 30 minutes before or 2 hours after meals 3
   • Contraindicated in patients with heart failure 1

2. Structured Exercise Program (should be implemented concurrently)

   • Supervised exercise for 30-45 minutes, at least 3 times weekly for minimum 12 weeks 1
   • Complements medication therapy for optimal results

Second-Line Therapy

• Pentoxifylline 400 mg three times daily
  • Only if cilostazol is contraindicated or not tolerated 1, 4
  • Marginal clinical effectiveness compared to cilostazol 1
  • Modest improvement in walking distance (21-29 meters for pain-free walking) 1
  • Class IIb recommendation (Level of Evidence: A) 1

Medications Not Recommended

• Gabapentin: Not indicated for claudication
• Naproxen: No evidence supporting use for claudication; may increase cardiovascular risk

Comparative Efficacy

• Direct comparison trials show cilostazol is significantly more effective than pentoxifylline 2
• In comparative studies, pentoxifylline was not significantly different from placebo, while cilostazol demonstrated significant improvements 4, 2

Important Considerations and Monitoring

• Common side effects of cilostazol: headache, diarrhea, abnormal stools, dizziness, and palpitations 1, 2
• Approximately 20% of patients may discontinue cilostazol within 3 months due to side effects 1
• Drug interactions: Dose reduction may be needed with CYP3A4 or CYP2C19 inhibitors 2
• Evaluate response after 12 weeks of therapy
• Concurrent antiplatelet therapy (aspirin 75-100 mg daily or clopidogrel 75 mg daily) is recommended for cardiovascular risk reduction 1

Comprehensive Management

• Risk factor modification is essential:
  • Smoking cessation
  • Statin therapy
  • Antihypertensive therapy if indicated
  • Diabetes management if applicable

Cilostazol has the strongest evidence base for improving claudication symptoms and walking distance in patients with PAD and should be the first-line pharmacologic therapy for this patient with an ABI of 0.70 and classic symptoms of intermittent claudication.