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Medical Therapies Provide Options for PAD Treatment
Evidence has amassed indicating benefits of several medications in this population.
In recent years, data have emerged showing a variety of medical therapies can improve outcomes of patients with peripheral artery disease.
In addition, following all relevant guidelines on medical therapy seems to benefit those with PAD and other CVDs, a panel of experts said at VIVA 18 in Las Vegas.
Role of Antiplatelet Therapy
Antiplatelet therapy — including agents such as aspirin, clopidogrel, ticagrelor (Brilinta, AstraZeneca) and prasugrel (Effient, Daiichi Sankyo/Eli Lilly) — appears to benefit patients with PAD.
However, while it is common practice to prescribe dual antiplatelet therapy after lower-extremity endovascular revascularization as is done after PCI, there are little data to support this, according to Mark F. Conrad, MD, director of clinical research and assistant program director in the division of vascular and endovascular surgery at Massachusetts General Hospital.
“No prior systematic reviews have focused solely on this subject,” Conrad said during a presentation. “Despite this, prescription of DAPT following such procedures is common, with data from survey studies and regional registries suggesting greater than 70% of providers routinely prescribe DAPT.”
Role of Rivaroxaban
The COMPASS trial “changed how we pay attention to” medical therapy in patients with PAD, Joshua Beckman, MD, director of vascular medicine and professor of medicine at Vanderbilt University Medical Center, said during a presentation.
In COMPASS, among patients with stable PAD, rivaroxaban (Xarelto, Janssen/Bayer) 2.5 mg plus aspirin conferred lower risk for MACE and major adverse limb events (MALE) compared with aspirin alone.
In contrast, Beckman said, while clopidogrel has been associated with reduction of MACE risk in this population, unlike rivaroxaban, it has not been linked to reduction of risk for all-cause mortality or MALE.
“Because of that, I’m not sure where [clopidogrel] fits in anymore,” he said.
Role of Vorapaxar
In the TRA2P-TIMI 50 trial, vorapaxar (Zontivity, Aralez) was shown to reduce risk for MACE, hospitalization for acute limb ischemia and peripheral revascularization in patients with PAD, regardless of whether they were symptomatic, Marc P. Bonaca, MD, MPH, executive director of CPC Clinical Research and director of vascular research and William R. Hiatt Endowed Chair for Cardiovascular Research at the University of Colorado, said.
“Reasons to consider vorapaxar include when there is use of a P2Y12 inhibitor either as monotherapy or DAPT; when there are renal concerns because it is not cleared by the kidneys; when there are adherence concerns because it is taken once daily, is well-tolerated and has a long half-life; and when the patient is unable to tolerate rivaroxaban,” he said.
Role of PCSK9 Inhibitors
While PCSK9 inhibitors are traditionally considered as a treatment for patients with CAD, analyses of the FOURIER trial showed that evolocumab (Repatha, Amgen) also benefited patients with PAD, Matthew T. Menard, MD, co-director of vascular and endovascular surgery and program director of the vascular and endovascular surgical fellowship at Brigham and Women’s Hospital and assistant professor of medicine at Harvard Medical School, said during a presentation.
Among the 1,505 patients with PAD but no prior MI or stroke in FOURIER, evolocumab was associated with reductions in CV death/MI/stroke and MALE, he said.
“FOURIER highlights significant potential to impact CV health in the PAD and CLI population through reduction of LDL down to very low levels,” he said. – by Erik Swain
- References:
- Beckman J. What is the Role for P2Y12 Therapy in PAD After COMPASS? PharmacoRx: Pharmacotherapy in PAD.
- Bonaca MP. Vorapaxar: Why, When, and in Whom? PharmacoRx: Pharmacotherapy in PAD.
- Bonaca MP, et al. Circulation. 2017;doi:10.1161/CIRCULATIONAHA.117.032235.
- Conrad MF. Is There a Role for Aspirin Monotherapy in PAD? PharmacoRx: Pharmacotherapy in PAD.
- Eikelboom JW, et al. N Engl J Med. 2017;doi:10.1056/NEJMoa1709118.
- Menard MT. Do the FOURIER Results Mandate Usage in PAD? PharmacoRx: Pharmacotherapy in PAD. All presented at: VIVA 18; Nov. 5-8, 2018; Las Vegas.
- Morrow DA, et al. N Engl J Med. 2012;doi:10.1056/NEJMoa1200933.
- For more information:
- Joshua Beckman, MD, can be reached at joshua.a.beckman@vanderbilt.edu; Twitter: @joshuabeckmanmd.
- Marc P. Bonaca, MD, MPH, can be reached at marc.bonaca@ucdenver.edu; Twitter: @marcbonaca.
- Marc F. Conrad, MD, can be reached at mconrad@partners.org.
- Matthew T. Menard, MD, can be reached at mmenard@bwh.harvard.edu.
Disclosures: Beckman reports he has consulted for AstraZeneca, Antidote Therapeutics, Bayer, Bristol-Myers Squibb, Janssen, Merck, Novartis and Sanofi Aventis and holds equity in EMX and Janacare. Bonaca reports he has consulted for Amgen, Aralez, AstraZeneca, Bayer, Janssen, Merck and Sanofi Aventis and has received research funding from Amgen, AstraZeneca, Merck, Medimmune and Pfizer. Conrad reports he has consulted for Bard Peripheral Vascular, Endologix and Medtronic. Menard reports he has consulted for Janssen.