What is the management of intermittent claudication in primary care according to National Institute for Health and Care Excellence (NICE) guidelines in the United Kingdom (UK)?

From the Guidelines

Management of intermittent claudication in primary care according to NICE guidelines in the UK should prioritize supervised exercise programs, as they have been shown to improve functional status and quality of life, and reduce leg symptoms, as recommended by the most recent guidelines 1. The cornerstone of management involves lifestyle modifications, including smoking cessation, which can significantly improve symptoms and reduce cardiovascular risk.

• Patients should be encouraged to participate in a supervised exercise program, ideally consisting of 2-3 sessions per week for a minimum of 3 months, with each session involving 30-60 minutes of walking exercise to the point of maximal pain tolerance.
• For cardiovascular risk reduction, all patients should be prescribed a statin (such as atorvastatin 20-80mg daily) and an antiplatelet agent (typically aspirin 75mg daily or clopidogrel 75mg daily if aspirin is contraindicated).
• Blood pressure should be controlled to a target of <140/90 mmHg, and diabetes should be optimally managed.
• Naftidrofuryl oxalate (200mg three times daily) can be offered as first-line pharmacological treatment specifically for claudication symptoms if supervised exercise has not led to satisfactory improvement and the patient still has lifestyle-limiting symptoms, as supported by previous guidelines 1.
• Patients should be reviewed every 3-6 months to assess symptom improvement, medication adherence, and side effects.
• If symptoms persist despite these measures, referral to vascular specialists should be considered for assessment for revascularization options, particularly if claudication is severely limiting daily activities or quality of life, as recommended by recent comparisons of guidelines 1. The benefits of supervised exercise programs are well-established, with improvements in maximal walking ability and quality of life, as demonstrated by a meta-analysis of 21 studies 1. In contrast, the effectiveness of unsupervised exercise programs is not well established, and therefore, supervised exercise should be the primary recommendation 1. Additionally, the use of antiplatelet and antithrombotic therapies, such as aspirin or clopidogrel, is recommended for the prevention of nonfatal MI, nonfatal stroke, or vascular death in patients with symptomatic PAD, as supported by guidelines on antithrombotic therapy 1. Overall, the management of intermittent claudication should prioritize supervised exercise, cardiovascular risk reduction, and appropriate medication, with referral to vascular specialists considered for patients with persistent symptoms, as recommended by the most recent and highest quality guidelines 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Intermittent Claudication in Primary Care

According to the National Institute for Health and Care Excellence (NICE) guidelines in the United Kingdom (UK), the management of intermittent claudication in primary care involves:

• Supervised exercise therapy (SET) as the first-line treatment for intermittent claudication 2, 3, 4
• SET improves walking distances, endothelial and mitochondrial function, muscle strength, and endurance, and leads to a generalized improvement in cardiovascular fitness and overall quality of life 4
• Revascularization may be considered for patients with occlusive disease of the aortoiliac tract and/or common femoral artery (inflow) 2
• Cilostazol, an antiplatelet treatment, may be used to improve walking distance in people with intermittent claudication secondary to peripheral arterial disease (PAD) 5

Uptake and Adherence to Supervised Exercise Programs

• The uptake of supervised exercise programs (SEPs) is low, with only 24.2% of patients with intermittent claudication recruited to SEPs 6
• Adherence to SEPs is also a concern, with only 75.1% of patients reportedly completing an SEP 6
• Reasons for poor uptake and adherence include lack of resource, patient withdrawal, and no reason for incomplete adherence reported 3, 6

Treatment Options

• SET is the primary treatment option for intermittent claudication, with revascularization and cilostazol considered as alternative or additional treatments 2, 3, 4, 5
• The choice of treatment depends on the individual patient's characteristics, such as the level of disease and the presence of comorbidities 2, 5