When should cilostazol (Pletal) be discontinued?

When to Stop Cilostazol (Pletal)

Cilostazol should be discontinued immediately in patients who develop congestive heart failure of any severity, thrombocytopenia, leukopenia progressing to agranulocytosis, or when significant side effects persist despite dose reduction. 1, 2

Absolute Contraindications Requiring Immediate Discontinuation

• Congestive heart failure of any severity: Cilostazol is contraindicated in patients with heart failure due to potential increased mortality risk related to its phosphodiesterase III inhibitor properties 1
• Hematologic abnormalities: Discontinue immediately if thrombocytopenia or leukopenia progressing to agranulocytosis develops (these conditions are reversible upon discontinuation) 2

Discontinuation Due to Side Effects

• Intolerable side effects: Consider discontinuation if patients experience persistent side effects despite dose reduction attempts 1
• Common side effects warranting consideration for discontinuation:
  • Severe headache (occurs in up to 25% of patients) 1, 3
  • Persistent diarrhea 1, 4
  • Palpitations or tachycardia 1, 4
  • Dizziness 1, 4

Timing of Evaluation for Discontinuation

• Initial tolerance assessment: Evaluate patient tolerance at 2-4 weeks after initiation 1
• Efficacy assessment: Evaluate clinical benefit within 3-6 months to determine if long-term therapy will be beneficial 1
• Discontinuation rate: In clinical practice, approximately 20% of patients discontinue cilostazol within the first 3 months due to side effects 1

Special Considerations for Discontinuation

• Prior to surgical procedures: Consider temporary discontinuation before major surgical procedures due to antiplatelet effects (though no specific guidelines exist for this) 4
• Development of new cardiovascular conditions: Reassess risk-benefit if patient develops new cardiac conditions 1
• Drug interactions: Consider discontinuation when starting medications that strongly inhibit CYP3A4 or CYP2C19, if dose reduction is not feasible 3

Monitoring During Treatment

• Cardiovascular monitoring: Regular assessment for development of heart failure symptoms 1
• Complete blood count: Monitor for rare but serious hematologic adverse effects 2
• Walking distance improvement: If no improvement in claudication symptoms after 3-6 months of therapy, consider discontinuation 1, 4

Clinical Pearls

• Temporary discontinuation: Side effects like headache often diminish after 2 weeks of therapy, so consider temporary dose reduction rather than immediate discontinuation for mild-moderate side effects 3
• Dose adjustment: Before complete discontinuation, consider reducing dose to 50mg twice daily if side effects occur at 100mg twice daily 5
• Risk-benefit assessment: Regularly reassess the benefit (improved walking distance) against risks (side effects, drug interactions) 1