Cilostazol is NOT Contraindicated in Grade II Diabetic Foot Disease
Cilostazol is not contraindicated in patients with grade II diabetic foot disease; in fact, it may be beneficial for improving wound healing and managing peripheral artery disease symptoms in these patients. The only absolute contraindication for cilostazol is heart failure of any severity 1, 2.
Understanding the Contraindication
The critical distinction here is that cilostazol's contraindication is specifically limited to heart failure, not diabetic foot disease:
- Cilostazol should not be administered to patients with congestive heart failure of any severity due to increased mortality risk associated with phosphodiesterase III inhibitors 1.
- The FDA has mandated a black box warning prohibiting its use in heart failure patients due to the potential to trigger ventricular tachycardia through increased intracellular cyclic AMP 1, 2.
- This contraindication applies to heart failure of any severity, not to diabetic foot disease or peripheral artery disease 1, 2.
Evidence Supporting Use in Diabetic Foot Disease
Multiple studies demonstrate cilostazol's potential benefits in diabetic foot patients:
- Cilostazol prevents foot ulcers in diabetic patients with peripheral vascular disease, with only 4.25% of cilostazol-treated patients developing foot ulceration compared to 35.48% in untreated patients over 16 months of follow-up 3.
- Wound healing is significantly faster with cilostazol compared to aspirin in diabetic foot ulcer patients, with 90% complete response in the cilostazol group versus 55% in the aspirin group 4, 5.
- Treatment with cilostazol (100 mg twice daily) improves walking distances significantly in diabetic patients with intermittent claudication and improves plasma lipid profiles 6.
Clinical Application Algorithm
Before prescribing cilostazol for grade II diabetic foot disease:
- Screen for heart failure - Assess for any history or current symptoms of heart failure (dyspnea, orthopnea, edema, reduced ejection fraction) 2.
- If heart failure is present - Do NOT prescribe cilostazol; consider supervised exercise therapy as first-line treatment 2.
- If no heart failure - Cilostazol 100 mg orally twice daily is appropriate and may improve wound healing 1, 7, 4.
- Assess tolerance at 2-4 weeks - Common side effects include headache, diarrhea, dizziness, and palpitations, with 20% discontinuation rates 1, 8.
- Evaluate benefit at 3-6 months - Determine whether long-term therapy provides sufficient clinical benefit to continue 1.
Important Caveats
- Cilostazol is indicated for claudication symptoms and improving walking distance, not specifically for tissue loss or gangrene, though evidence suggests wound healing benefits 7, 3, 4.
- The drug requires continuous administration with an 11-hour half-life, making it impractical for immediate tissue salvage decisions 7.
- For severe ischemia with dry gangrene, urgent vascular surgery consultation remains mandatory to assess revascularization options, regardless of cilostazol use 7.