Q 1: What risk factors and elements of E.P.’s presentation are consistent with a diagnosis of IC?

Risk Factors:

• Smoking
• Diabetes
• Being overweight
• Sedentary lifestyle
• High cholesterol
• High blood pressure
• Older age (55 for men)

Clinical Presentation

• Right upper thigh pain while walking
• The pain is relieved within minutes after he stops walking
• Ankle-to-brachial index (ABI) is 0.7 (normal: > 0.90).

 

Q 2: What are the therapeutic goals in treating E.P. and what interventions should be initiated to prevent claudication pain and arrest progression of his disease?

Therapeutic goals:

• HbA1c goal <7.0 percent, fasting blood glucose <100
• Total cholesterol <200, LDL <100, HDL >40, trigs <150,
• BP <120/80

In order to achieve these therapeutic goals, patient needs to adapt some lifestyle modifications such as smoking cessation, healthy diet, reduce weight, and initiate exercise. Also, as a provider, I need to make sure that the patient is adherent to the current medication regimen before adding other therapeutic agents. For the HbA1c level, I would initiate anti-diabetic medication, metformin. For the dyslipidemia, high statin therapy of atorvastatin will be initiated, and for BP control the current medication Ramipril can be titrated to 10mg if the Cilostazol does not lower the BP.

 

Q 3: Is lipid-lowering therapy indicated for E.P.?

 

Lipid lowering agent is indicated because clinical guidelines suggest targeting for LDL<100mg/dl while our patient LDL level is 188 and above the target. Additionally, according to the American Heart Association, diabetes mellitus patient between the age of 50-75 are in higher risk, so they should be placed on “high-intensity statin to reduce the LDL-C level by ≥50%. Furthermore, a meta-analysis of randomized trial reveals that patient with PAD benefits from statin therapy as it reduces cardiovascular mortality and morbidity.  Therefore, I would start the patient on a high intensity statin of Atorvastatin 40 mg PO Daily.

 

Q4:  How would you manage E.P.’s antihypertensive medication?

 

In this visit, I am not going to prescribe any anti-hypertensive drug because I am prescribing Cilostazol 100mg PO twice daily, which has a side effect of lowing blood pressure. Patient body is used to high blood pressure, so I do not want to drastically decrease the BP and cause organ damage. I would want to see the patient in 4 weeks in order to check on the efficacy of cilostazol and its effect on BP. If the blood pressure is still on the high range, then I would titrate the Ramipril 10 mg orally once a day because Ramipril reduces the risk of MI, stroke, or death from cardiovascular cause in patient 55 years or older.

 

Q5: Will improving E.P.’s diabetes control or slow the progression of his PAD? What changes in his diabetes management do you recommend?

 

Diabetes is second most common risk factor for PAD after smoking, so glycemic control should help to reduce complications caused by DM. Diabetes enhances “vascular inflammation, endothelial dysfunction, vasoconstriction, platelet activation, and thrombotic risk” which eventually leads to PAD so glycemic control can slow the progression. Our patient has a Hgb A_1C 10.5%, so aggressive glycemic control can lower the HbA1c level and reduce complications. I would use first line agent such as Metformin 500 mg PO TID. Once the patient comes back for routine checkup in four weeks, and if the fasting glucose is still elevated, then I would add Liraglutide 0.6 mg SQ once daily for 1 week then 1.2 mg SQ once daily (5). After 3 months I would check the patient Hgb A_1C to determine further need of glycemic control medications

 

Q6: Is E.P.’s ASA therapy beneficial for preventing further complications of IC? Are there any medications that can be used to increase the walking ability of E.P.?

 

Patient with PAD symptoms really benefits with long term antiplatelet therapy as it reduces the incidence of cardiovascular events. Dual antiplatelet therapy is not recommended for diabetic patient with PAD.  Therefore, I would discontinue ASA and prescribe Clopidogrel 75 mg PO daily because a randomized trial of 19,185 patients revels Clopidogrel had significant benefits over Aspirin (325 mg/daily) in reducing ischemic stroke, myocardial infarction (MI), or vascular death among patients with DM and PAD (4).

 

In order to improve patient’s symptoms and increase walking ability, I would prescribe Cilostazol 100mg PO twice daily, and the medication should be taken at least half hour before eating or 2 hours after eating because high fat increase absorption (2). Cilostazol usually exhibits benefits within four-week of initiating therapy. Cilostazol is a phosphodiesterase inhibitor that suppresses platelet aggregation and causes atrial vasodilation, meaning it can cause the blood pressure to drop. I am also initiating statin therapy, which can also improve walking parameter. Finally, multiple studies illustrate that exercise significantly improves walking parameters in PAD patient, so I would recommend the patient to perform low intensity exercise such as: walking, cycling, resistance/strength training, swimming or any other form of exercise.

 

Complete Regimen:

1. Isosorbide mononitrate 60 mg daily
2. Ramipril5 mg daily.
3. NPH insulin 40 units in the morning and 35 units in the evening
4. Metformin 500 mg PO TID
5. Atorvastatin 40 mg PO Daily
6. Clopidogrel 75 mg PO Daily
7. Cilostazol 100mg PO twice Daily

 

 

Sources:

1. https://www.hopkinsmedicine.org/health/conditions-and-diseases/claudication
2. https://www-uptodate-com.york.ezproxy.cuny.edu/contents/management-of-claudication-due-to-peripheral-artery-disease?search=Intermittent%20claudication&source=search_result&selectedTitle=2~78&usage_type=default&display_rank=2#H11
3. https://www.drugs.com/dosage/ramipril.html
4. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet 1996; 348:1329.
5. Marso SP, Daniels GH, Brown-Frandsen K, et al. Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med 2016; 375:311.
6. https://www-uptodate-com.york.ezproxy.cuny.edu/contents/overview-of-peripheral-artery-disease-in-patients-with-diabetes-mellitus?search=Diabeted%20effect%20on%20PAD&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H2213373642