Intermittent claudication is muscle pain on exercise relieved by rest. It is most
often caused by atherosclerotic narrowing of the iliac and femoral arteries, often
combined with lesions in distal arteries of the leg. It may affect as many as 5% of
men over 50 years. For some the symptoms improve. For 10-20% they progress, and in
perhaps one in 20 amputation is necessary because of a gangrenous limb.
Exercise therapy has been shown to be effective in increasing pain free walking time
(
Bandolier 52
). Two new systematic reviews [1,2] examine additional aspects of medical management.
Search
Both reviews came from the same team in Padua and Amsterdam. Searching was English
language medical literature using MEDLINE. One review [1] examined physical training,
smoking cessation, pentoxifylline or nafronyl. The other [2] examined antithrombotic
treatments.
Results
The results from both reviews are reviewed briefly.
Physical training [1]
There were seven randomised but open studies of physical training. The comparison
was usually placebo tablets or usual activity, and training consisted of 30-60 minute
training sessions several times a week for three to six months. Studies were small,
the largest being about 40 patients.
Four studies (94 patients total) had information on pain free walking distance,
which was increased by a mean of 139 metres (95% confidence interval 31 to 247
metres; Figure 1). The total walking distance was increased by 179 metres (60 to 298
metres).
Figure 1: Pain free walking distance with training
Stopping smoking [1]
Only four non randomised studies on the effects of smoking cessation in 183
patients were found. Included patients were smokers on referral, or who had
stopped smoking in the previous six months. There was no consistency in the
results, which are probably uninterpretable.
Pentoxifylline [1]
There were six randomised, double-blind studies (600 patients total) with
information on pain free walking distance (Figure 2). The mean increase in pain
free walking distance over two to six months on 400-1200 mg a day compared with
placebo was 21 metres (1 to 41). The total walking distance was increased by 44
metres (14 to 74 metres) in seven studies.
Figure 2: Pain free walking distance with Pentoxifylline
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Nafronyl [1]
Four randomised, double-blind studies (409 patients total) had information on
pain free walking distance (Figure 3). The mean increase in pain free walking
distance over three to six months on 400-800 mg a day compared with placebo was
59 metres (30 to 87). The total walking distance was increased by 71 metres (13
to 129 metres) in two studies.
Figure 3: Pain free walking distance with Nafronyl
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Antithrombotics [2]
Studies of antithrombotics versus placebo or no treatment were generally small,
and with few patients on any one treatment. Those with at least three studies
and/or 200 patients in a comparison and which showed benefit included:
Indobrufen: 400 mg a day over six to 12 months produced a mean increase in pain
free walking distance of 451 metres and 74 metres in two trials with a total of
354 patients.
Low molecular weight heparin at 8,000 or 15,000 units a day for six months
produced a mean increase in pain free walking distance of 53 metres (20 to 87
metres) in three trials with 135 patients.
Sulodexide at 600-1000 units a day for 70 days produced a mean increase in pain
free walking distance of 113 metres (77 to 148 metres) in six trials with 209
patients.
Comment
Exercise training again appears to be a good buy for patients with intermittent
claudication, as part of overall management. At least these reviews tell us what
knowledge there is in some areas of treatment for this disorder. Gathering
together the best available evidence at least tells us where we are, even if its
not where we want to be.
Reference:
- B Girolami et al. Treatment of intermittent claudication with physical
training, smoking cessation, pentoxifylline, or nafronyl. Archives of Internal
Medicine 1999 159: 337-345.
- B Girolami et al. Antithrombotic drugs in the primary medical management of
intermittent claudication: a meta-analysis. Thromb Haemost 1999 81:
715-722.
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