Pharmacotherapy Case: Peripheral Artery Disease (PAD) Management by Dr. Nehad Jaser

Age: 65 years
Gender: Male

Subjective Data

Chief Complaint:
“I get sharp pain in my calves when I walk, but it goes away when I rest.”

History of Present Illness:
Mr. Carter is a 65-year-old male with a 3-year history of PAD, presenting for routine follow-up. He reports worsening bilateral calf pain (claudication) after walking 1 block, resolving within 5 minutes of rest. He denies rest pain, foot ulcers, or color changes. He admits to non-adherence with prescribed cilostazol due to headaches.

Medical History:

  • PAD (diagnosed 3 years ago, no prior revascularization).

  • Type 2 diabetes mellitus (HbA1c 8.0%).

  • Hypertension.

  • Hyperlipidemia.

  • 30-pack-year smoking history (quit 6 months ago).

Family History:

  • Father: Myocardial infarction at 60.

  • Mother: Type 2 diabetes.

Social History:

  • Retired construction worker, sedentary lifestyle.

  • Quit smoking 6 months ago; no alcohol use.

Medications:

  • Aspirin 81 mg PO daily

  • Atorvastatin 40 mg PO nightly

  • Lisinopril 10 mg PO daily

  • Metformin 1000 mg PO BID

  • Cilostazol 100 mg PO BID (self-discontinued 2 months ago)

Allergies:

  • No known drug allergies.

Adherence:

  • 50% adherence to cilostazol; otherwise compliant with other medications.

Objective Data

Vital Signs:

  • BP: 150/90 mmHg (right arm, seated)

  • HR: 78 bpm

  • RR: 16 breaths/min

  • Weight: 88 kg

  • Height: 175 cm

  • BMI: 28.8 kg/m²

Physical Exam:

  • Cardiovascular: Regular rhythm, no murmurs. Diminished bilateral dorsalis pedis and posterior tibial pulses.

  • Musculoskeletal: Calf muscles tender to palpation; no atrophy.

  • Skin: Cool lower extremities; no ulcers or gangrene.

Laboratory Results:

  • LDL: 110 mg/dL (↓ from 160 mg/dL pre-statin)

  • HbA1c: 8.0%

  • Creatinine: 1.0 mg/dL (eGFR >60 mL/min/1.73m²)

Diagnostics:

  • Ankle-Brachial Index (ABI): 0.7 bilaterally (normal ≥1.0).

  • Doppler Ultrasound: Moderate stenosis of bilateral superficial femoral arteries.

Assessment

  1. Symptomatic PAD (Rutherford Category 3):

    • Claudication limiting daily activities (walking <1 block).

    • ABI 0.7 confirms moderate-severe disease.

  2. ASCVD Risk Factors:

    • Diabetes, hypertension, hyperlipidemia, smoking history.

    • ASCVD 10-year risk: 30% (very high risk).

  3. Medication Non-Adherence:

    • Self-discontinued cilostazol due to side effects.

  4. Uncontrolled Comorbidities:

    • BP above goal (<130/80 mmHg for diabetes).

    • HbA1c elevated (goal <7%).

Plan

  1. Pharmacotherapy:

    • Antiplatelet Therapy: Continue aspirin 81 mg daily (first-line for PAD).

    • Symptom Management: Restart cilostazol 50 mg PO BID (lower dose to reduce headache risk). If tolerated, escalate to 100 mg BID in 2 weeks.

    • Statin Optimization: Maintain atorvastatin 40 mg (LDL goal <70 mg/dL).

    • BP Control: Increase lisinopril to 20 mg PO daily. Add amlodipine 5 mg PO daily if BP remains >130/80 mmHg.

    • Diabetes Management: Add empagliflozin 10 mg PO daily (improves CV outcomes in diabetes).

  2. Monitoring:

    • ABI and symptom progression annually.

    • HbA1c in 3 months; BP check in 2 weeks.

    • Liver enzymes and CK at next visit (statin safety).

  3. Lifestyle Modifications:

    • Supervised exercise program (walking 30–45 min/day, 3–5x/week).

    • Referral to dietitian for diabetes-friendly, low-sodium diet.

  4. Education:

    • Foot care: Daily inspection, moisturize, avoid barefoot walking.

    • Smoking cessation reinforcement.

    • Importance of medication adherence; report recurrent headaches or palpitations.

  5. Follow-Up:

    • Return in 4 weeks to assess cilostazol tolerance, BP, and claudication symptoms.

Rationale:

  • Cilostazol improves claudication symptoms via vasodilation and antiplatelet effects. Dose escalation mitigates side effects.

  • Empagliflozin reduces cardiovascular risk in diabetic patients with established ASCVD.

  • Aggressive LDL lowering (atorvastatin) and BP control slow PAD progression.

  • Exercise therapy is a Class IA recommendation for claudication.

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