What is Cilostazol (Pletal) used for?

Cilostazol Use in Clinical Practice

Cilostazol (Pletal) is primarily indicated for the reduction of symptoms of intermittent claudication in patients with peripheral arterial disease (PAD), as demonstrated by an increased walking distance. 1

Primary Indication and Mechanism of Action

• Cilostazol is a phosphodiesterase type III inhibitor that increases cyclic adenosine monophosphate (cAMP), providing vasodilator and platelet inhibitory properties 2, 1
• The medication improves maximal walking distance by 40% to 60% compared with placebo after 12 to 24 weeks of therapy in patients with intermittent claudication 2
• Cilostazol has been shown to significantly improve quality of life and lower limb functional status in patients with PAD 2, 3

Dosing and Administration

• The recommended dose is 100 mg orally twice daily, which is more effective than 50 mg twice daily 2
• It is important to assess patient tolerance at 2-4 weeks and evaluate benefit within 3-6 months to determine if long-term therapy will be beneficial 2
• Approximately 20% of patients discontinue cilostazol within 3 months due to side effects 2

Clinical Benefits Beyond Symptom Relief

• Cilostazol modestly increases ankle-brachial index (ABI), though this hemodynamic effect does not fully account for the improvement in claudication symptoms 2
• Recent data suggest cilostazol may reduce restenosis after endovascular therapy for femoropopliteal disease 2
• The medication has beneficial effects on lipid profiles, increasing HDL cholesterol and decreasing triglyceride concentrations 2, 1, 4

Important Contraindications and Safety Considerations

• Cilostazol is absolutely contraindicated in patients with heart failure of any severity 2, 5
• The FDA has mandated a black box warning against use in heart failure patients due to concerns about increased mortality risk associated with phosphodiesterase III inhibitors in this population 2, 5
• Common side effects include headache (most frequent), diarrhea, abnormal stools, palpitations, and dizziness 2, 3
• Long-term safety studies have not demonstrated significant increases in mortality or major cardiovascular events in patients without heart failure 2, 6

Comparative Efficacy

• Cilostazol is superior to pentoxifylline for improving walking distance in patients with intermittent claudication 2, 3
• In a 24-week randomized controlled trial, pentoxifylline showed no significant difference compared to placebo in maximal walking distance, while cilostazol demonstrated significant improvement 2
• Current guidelines recommend cilostazol as first-line pharmacotherapy for claudication, with pentoxifylline considered only as a second-line alternative with marginal clinical effectiveness 2

Clinical Algorithm for Use

1. Confirm diagnosis of PAD with intermittent claudication 2
2. Screen for contraindications, particularly heart failure of any severity 2, 5
3. Start cilostazol 100 mg twice daily if no contraindications exist 2, 1
4. Assess for side effects at 2-4 weeks 2
5. Evaluate clinical benefit at 3-6 months 2
6. Continue therapy if beneficial and well-tolerated 2, 7

Cilostazol represents an important pharmacological option for patients with intermittent claudication who have not adequately responded to exercise therapy or who require additional symptom relief to improve quality of life and functional capacity 2, 3.