Buerger's disease medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]
Overview
There is no treatment for Buerger's disease. In order to prevent progression and control symptoms smoking cessation is crucial. Smoking cessation does not reverse damage already caused. Pharmacologic medical therapies for Buerger's disease include smoking cessation, palliative treatments, prostaglandin analogs and phosphodiesterase inhibitors, calcium channel blockers, endothelin receptor anatagonists, compression therapy and some experimental therapies. It should be noted, however, that these therapies are purely palliative and do not reverse previous damage caused.
Medical Therapy
Pharmacologic medical therapies for Buerger's disease include smoking cessation, palliative treatments, prostaglandin analogs and phosphodiesterase inhibitors, calcium channel blockers, endothelin receptor anatagonists, compression therapy and some experimental therapies. It should be noted, however, that these therapies are purely palliative and do not reverse previous damage caused.
Smoking cessation
- Smoking cessation is crucial to the management of Buerger's disease. Not only does smoking cessation halt progression but also controls pain symptoms and decreases the risk of amputation.
- The patient may, however, still suffer from intermittent cluadication or Reynaud's phenomenon.
- Complete abstinence from smoking is a must as Buerger's disease in susceptible individuals can be triggered by a single cigarette.
- Any anti-smoking aid containing nicotine such as transdermal patches or gum must be avoided as they may also trigger the disease.
- Anti-smoking aids such as bupropion or varenicline may be of use and do not contribute to disease progression.
- A patient that claims to have stopped smoking but continues to suffer symptoms of active disease should be tested for urinary nicotine and cotinine.
- Previous studies have demonstrated that only 50% of patients with Buerger's disease are able to quit smoking. In these patients, nicotine dependence treatment may be sought.
Iloprost
- Iloprost is a prostaglandin analog and is available in an IV and oral form.
- Iloprost is especially effective in the intravenous form at reducing pain symptoms, better than low dose aspirin or lumbar sympathectomy.
- Iloprost can facilitate smoking cessation and may be used to manage resting pain symptoms in those patients with critical limb ischemia.
- Iloprost may also hasten ulcer healing.
Calcium channel blockers
- Calcium channel blockers are used in patients whose main complaint is Raynaud's phenomenon.
- Calcium channel blockers that prevent vasospasm include the dihydropyridines such as, nifedipine, nicardipine and, amlodipine.
Intermittent pneumatic compression
- Intermittent pneumatic compression (IPC) is used in patients whose main complaint is that of poor circulation and healing in the extremities.
- IPC is a therapy that is able to increase the flow of blood through the arteries by decreasing the peripheral arterial resistance.
Experimental therapies
Therapeutic angiogenesis
- Patients with ischemic pain or non-healing ulcers may benefit from therapeutic angiogenesis that uses grow factors, such as intramuscular vascular endothelial growth factor, or through the introduction of a Kirschner wire placed in the medullary canal of the tibia in order to promote the generation of blood vessels.
- Therapeutic angiogenesis has also demonstrated that it may reduce the occurrence of nocturnal resting pain.
Autologous bone marrow mononuclear cell implantation
- When traditional revascularization interventions have failed in those with severe peripheral artery disease, autologous bone marrow mononuclear cell implantation may be performed.
- Autologous bone marrow mononuclear cell implantation may be able to relieve ischemic pain symptoms and decrease ulcer size, whilst increasing walking distance.
Immunoabsorption therapy, bosentan and cilostazol
- Immunoabsorption therapy and bosentan (endothelin receptor antagonist) have demonstrated that they are effective in improving pain intensity and ulcer healing.
- Cilostazol (phosphodiesterase inhibitor) is a suppressor of platelet aggregation and a direct arterial vasodilator, it is able to casue a reactive hyperemia and therefore, improve blood flow.
Analgesia
- Non-steroidal anti-inflammatory drugs may be used to relieve pain symptoms, including naproxen,ibuprofen, indomethacin, diclofenac, and ketofen.
- Acetaminophen used alone, or with codeine or hydrocodone, is also effective.
Management of ulcers
Digit ulcerations are managed as with other ischemic wounds, debridement and moist dressing. Negative pressure wound therapy is becoming popular for the management of open wounds and has been used in the management of open wounds associated with thromboangiitis obliterans [64]. General considerations for the clinical assessment and management of open wounds are discussed in elsewhere. (See "Clinical assessment of wounds" and "Negative pressure wound therapy".)