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 antagonists, compression therapy and some experimental therapies. It should be noted, however, that these therapies are purely palliative and do not reverse previous damage caused. Analgesics including NSAIDs and acetaminophen may be used to provide pain relief.
Medical Therapy
Pharmacologic medical therapies for Buerger's disease include smoking cessation, palliative treatments, prostaglandin analogs and phosphodiesterase inhibitors, calcium channel blockers, endothelin receptor antagonists, compression therapy and some experimental therapies. It should be noted, however, that these therapies are purely palliative and do not reverse previous damage caused.[1][2][3]
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.[1][2][3]
- The patient may, however, still suffers from intermittent claudication or Raynaud 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 intravenous and oral forms.[4][5][6]
- Iloprost is expensive and not available in the USA.
- 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 phenomenon.[1]
- 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.[7]
- 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 (distraction osteogenesis) in order to promote the generation of blood vessels.[8] [9][10][11]
- 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.[8]
- 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.[12] [13]
- 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.[14]
Analgesia
- Non-steroidal anti-inflammatory drugs may be used to relieve pain symptoms, including naproxen,ibuprofen, indomethacin, diclofenac, and ketofen.[1][2]
- Acetaminophenused alone, or with codeine or hydrocodone, is also effective.
Management of ulcers
- Digital ulcers may be treated with debridement and moist dressing.[15]
- Negative pressure wound therapy may be of benefit in open wounds.
References
- ↑ 1.0 1.1 1.2 1.3 Olin JW (September 2000). "Thromboangiitis obliterans (Buerger's disease)". N. Engl. J. Med. 343 (12): 864–9. doi:10.1056/NEJM200009213431207. PMID 10995867.
- ↑ 2.0 2.1 2.2 Olin JW, Young JR, Graor RA, Ruschhaupt WF, Bartholomew JR (November 1990). "The changing clinical spectrum of thromboangiitis obliterans (Buerger's disease)". Circulation. 82 (5 Suppl): IV3–8. PMID 2225420.
- ↑ 3.0 3.1 Ohta T, Ishioashi H, Hosaka M, Sugimoto I (January 2004). "Clinical and social consequences of Buerger disease". J. Vasc. Surg. 39 (1): 176–80. doi:10.1016/j.jvs.2003.08.006. PMID 14718836.
- ↑ "Oral iloprost in the treatment of thromboangiitis obliterans (Buerger's disease): a double-blind, randomised, placebo-controlled trial. The European TAO Study Group". Eur J Vasc Endovasc Surg. 15 (4): 300–7. April 1998. PMID 9610341.
- ↑ Fiessinger JN, Schäfer M (March 1990). "Trial of iloprost versus aspirin treatment for critical limb ischaemia of thromboangiitis obliterans. The TAO Study". Lancet. 335 (8689): 555–7. PMID 1689791.
- ↑ Bozkurt AK, Köksal C, Demirbas MY, Erdoğan A, Rahman A, Demirkiliç U, Ustünsoy H, Metin G, Yillik L, Onol H, Cinar B, Karaçelik M, Erdinç I, Bolcal C, Sayin AG (June 2006). "A randomized trial of intravenous iloprost (a stable prostacyclin analogue) versus lumbar sympathectomy in the management of Buerger's disease". Int Angiol. 25 (2): 162–8. PMID 16763533.
- ↑ Labropoulos N, Watson WC, Mansour MA, Kang SS, Littooy FN, Baker WH (October 1998). "Acute effects of intermittent pneumatic compression on popliteal artery blood flow". Arch Surg. 133 (10): 1072–5. PMID 9790203.
- ↑ 8.0 8.1 Isner JM, Baumgartner I, Rauh G, Schainfeld R, Blair R, Manor O, Razvi S, Symes JF (December 1998). "Treatment of thromboangiitis obliterans (Buerger's disease) by intramuscular gene transfer of vascular endothelial growth factor: preliminary clinical results". J. Vasc. Surg. 28 (6): 964–73, discussion 73–5. PMID 9845647.
- ↑ Saito S, Nishikawa K, Obata H, Goto F (2007). "Autologous bone marrow transplantation and hyperbaric oxygen therapy for patients with thromboangiitis obliterans". Angiology. 58 (4): 429–34. doi:10.1177/0003319706292015. PMID 17652224.
- ↑ Inan M, Alat I, Kutlu R, Harma A, Germen B (March 2005). "Successful treatment of Buerger's Disease with intramedullary K-wire: the results of the first 11 extremities". Eur J Vasc Endovasc Surg. 29 (3): 277–80. doi:10.1016/j.ejvs.2004.12.011. PMID 15694801.
- ↑ Kulkarni S, Kulkarni G, Shyam AK, Kulkarni M, Kulkarni R, Kulkarni V (September 2011). "Management of thromboangiitis obliterans using distraction osteogenesis: A retrospective study". Indian J Orthop. 45 (5): 459–64. doi:10.4103/0019-5413.83954. PMC 3162685. PMID 21886930.
- ↑ Kim HJ, Jang SY, Park JI, Byun J, Kim DI, Do YS, Kim JM, Kim S, Kim BM, Kim WB, Kim DK (August 2004). "Vascular endothelial growth factor-induced angiogenic gene therapy in patients with peripheral artery disease". Exp. Mol. Med. 36 (4): 336–44. doi:10.1038/emm.2004.44. PMID 15365252.
- ↑ De Haro J, Acin F, Bleda S, Varela C, Esparza L (February 2012). "Treatment of thromboangiitis obliterans (Buerger's disease) with bosentan". BMC Cardiovasc Disord. 12: 5. doi:10.1186/1471-2261-12-5. PMC 3306190. PMID 22333218.
- ↑ Yasuda K, Sakuma M, Tanabe T (1985). "Hemodynamic effect of cilostazol on increasing peripheral blood flow in arteriosclerosis obliterans". Arzneimittelforschung. 35 (7A): 1198–200. PMID 4074434.
- ↑ Canter HI, Isci E, Erk Y (February 2009). "Vacuum-assisted wound closure for the management of a foot ulcer due to Buerger's disease". J Plast Reconstr Aesthet Surg. 62 (2): 250–3. doi:10.1016/j.bjps.2007.09.031. PMID 17980686.