What is the medical management of peripheral occlusive arterial disease in diabetes?

Medical Management of Peripheral Arterial Disease in Diabetes

All diabetic patients with peripheral arterial disease require aggressive cardiovascular risk reduction with statins targeting LDL-C <55 mg/dL, SGLT2 inhibitors or GLP-1 receptor agonists for glucose control, antiplatelet therapy with aspirin or clopidogrel, and meticulous foot care with daily inspection. 1

Lipid Management

Initiate high-intensity statin therapy immediately in all diabetic patients with PAD, targeting LDL-C <1.4 mmol/L (55 mg/dL) with a >50% reduction from baseline. 1

• Start with maximally tolerated statin therapy as first-line treatment 1
• If LDL-C target not achieved on statin monotherapy, add ezetimibe 1
• If target still not met on statin plus ezetimibe, add a PCSK9 inhibitor 1
• For statin-intolerant patients at high cardiovascular risk who fail to reach LDL-C goals on ezetimibe, add bempedoic acid alone or combined with a PCSK9 inhibitor 1
• Do not use fibrates for cholesterol lowering 1

Glucose Control

Prioritize SGLT2 inhibitors or GLP-1 receptor agonists with proven cardiovascular benefit over other glucose-lowering agents, independent of baseline HbA1c. 1

• Target HbA1c <7% (53 mmol/mol) to reduce microvascular complications 1
• SGLT2 inhibitors with proven cardiovascular benefit reduce cardiovascular events in diabetic patients with PAD 1
• GLP-1 receptor agonists with proven cardiovascular benefit reduce cardiovascular events in diabetic patients with PAD 1
• Individualize HbA1c targets based on comorbidities, diabetes duration, and life expectancy 1
• Avoid hypoglycemia, which poses particular risk in PAD patients 1
• Select glucose-lowering agents with proven cardiovascular benefits first, followed by agents with proven cardiovascular safety, over agents without such evidence 1

Antiplatelet Therapy

Use aspirin 75-160 mg daily OR clopidogrel 75 mg daily as monotherapy to reduce major adverse cardiovascular events. 1, 2

• Aspirin (75-325 mg daily) reduces risk of myocardial infarction, stroke, and vascular death in symptomatic PAD 1
• Clopidogrel (75 mg daily) is an effective alternative to aspirin and may provide superior benefit in PAD patients specifically 1, 2
• Do not use long-term dual antiplatelet therapy routinely in PAD patients 1
• Do not use oral anticoagulation monotherapy for PAD unless another indication exists 1
• Do not routinely use ticagrelor in PAD patients 1

Blood Pressure Management

Target systolic blood pressure toward 120-129 mmHg if tolerated in diabetic patients with PAD. 1

• Antihypertensive therapy reduces risk of myocardial infarction, stroke, heart failure, and cardiovascular death 1
• Beta-blockers are safe and effective in PAD patients and do not adversely affect walking capacity 1
• ACE inhibitors are reasonable for symptomatic PAD patients to reduce adverse cardiovascular events 1
• In patients with unilateral renal artery stenosis, include ACE inhibitors or ARBs in the antihypertensive regimen 1

Foot Care and Wound Prevention

Implement comprehensive foot care protocols with daily inspection, appropriate footwear, and immediate treatment of any skin lesions. 1

• Daily foot inspection by patients and physicians enables early identification of lesions 1
• Use appropriate footwear and provide chiropody/podiatric medicine services 1
• Apply topical moisturizing creams for skin care 1
• Address skin lesions and ulcerations urgently 1
• Measure toe pressure and transcutaneous oxygen pressure (TcPO2) in diabetic patients with PAD 3
• Diabetic foot ulcers typically heal if toe pressure >55 mmHg and TcPO2 >50 mmHg 3

Exercise Therapy

Prescribe supervised exercise training as initial treatment for symptomatic PAD patients. 1

• Supervised exercise training (SET) improves overall and pain-free walking distance 1
• Moderate-to-high intensity aerobic activities are recommended 1
• Continue SET as adjuvant therapy in patients undergoing endovascular revascularization 1

Smoking Cessation

Advise all diabetic PAD patients who smoke to stop at every visit and offer pharmacotherapy with varenicline, bupropion, or nicotine replacement. 1

• Provide behavioral counseling and develop a structured cessation plan 1
• Offer one or more pharmacological therapies: varenicline, bupropion, or nicotine replacement 1
• Smoking cessation improves leg symptoms and reduces cardiovascular events 4

Diagnostic Monitoring

Measure ankle-brachial index (ABI) for initial diagnosis, and use toe pressure or toe-brachial index (TBI) if ABI is normal in diabetic patients. 1

• ABI measurement is essential in diabetic patients over 50 with atherosclerosis risk factors 3
• Toe pressure and TBI are recommended when resting ABI is normal in diabetic or renal failure patients 1
• Duplex ultrasound (DUS) is the first-line imaging method to confirm PAD lesions 1
• CTA and/or MRA are recommended for symptomatic patients with aorto-iliac or multisegmental disease prior to revascularization 1

Critical Pitfalls to Avoid

• Never use compression therapy if ABI <0.6 without arterial assessment 3
• Do not assume bilateral edema in diabetic PAD patients is purely venous; always exclude systemic causes 3
• Avoid hypoglycemia, which increases cardiovascular risk in PAD patients 1
• Do not delay treatment of foot lesions or ulcerations 1
• Do not use fibrates for cholesterol lowering in PAD patients 1