Antithrombotic Therapy in Peripheral Arterial Occlusive Disease: Ticlopidine
Ticlopidine has also been evaluated in patients with intermittent claudication. Reports from Europe (level II) have shown a beneficial effect of ticlopidine for relieving symptoms, increasing walking distance, and improving lower-extremity ankle pressure indexes. In addition, a meta-analysis of these trials has demonstrated that patients with intermittent claudication treated with ticlopidine had a significant reduction in fatal and nonfatal cardiovascular events in comparison with patients treated with placebo. In a multicenter, randomized clinical trial, use of ticlopidine (250 mg/d) in patients with claudication was shown to result in a need for fewer vascular surgery procedures over a 7-year period than use of a placebo control The need for subsequent vascular surgery was reduced by about half (relative risk, 0.486; p < 0.001). The specific indications for the subsequent vascular procedures were not addressed, nor was the risk of adverse events such as neutropenia. Ticlopidine is associated with adverse hematologic effects generally not associated with aspirin. In addition to neutropenia, thrombotic thrombocytopenic purpura has recently been reported in 60 patients taking ticlopidine. Although promising, there is a need for confirmatory studies before ticlopidine can be recommended.
A compelling reason to administer aspirin to patients with peripheral arterial disease is to prevent death and disability from stroke and MI. In the original meta-analysis from the Antiplatelet Trialists, 31 randomized trials with more than 29,000 patients with vascular disease were analyzed and the data convincingly showed that long-term aspirin therapy significantly reduced overall vascular mortality, as well as nonfatal stroke and MI. Canadianfamilypharmacy more An update of this meta-analysis reviewed 174 randomized trials of antiplatelet therapy involving more than 100,000 patients Among high-risk patients, aspirin therapy was protective, reducing nonfatal MI by one third, nonfatal stroke by one third, and death from all vascular causes by one sixth. The beneficial effect was noted for men and women of all ages and was unrelated to the presence of diabetes and hypertension. Specific subgroup analyses of patients with peripheral arterial insufficiency and infrainguinal arterial reconstructions were considered, and both groups benefited from aspirin therapy. For all conditions, aspirin at 80 to 325 mg/d was at least as effective as any other regimen, including higher-dose aspirin therapy that is more prone to cause side effects and GI complications.