Management of Arterial Leg Ulcers

Current Evidence on Pentoxifylline

The American College of Cardiology and American Heart Association guidelines state that parenteral administration of pentoxifylline is not useful for the treatment of critical limb ischemia (Class III recommendation, Level of Evidence B) 1, 2
Pentoxifylline is a xanthine derivative with vasodilator and hemorheologic properties that might theoretically help in patients with critical limb ischemia (CLI) 1
Two placebo-controlled trials evaluated parenteral pentoxifylline (600 mg IV, twice daily) for CLI with inconsistent results - one showed reduced pain scores while the other showed no significant benefit 1
Cilostazol, another medication approved for intermittent claudication, has not been adequately evaluated to demonstrate efficacy in patients with CLI 1

Oral pentoxifylline (400 mg three times daily) has shown efficacy for venous ulcers, particularly when combined with compression therapy 4, 5
A meta-analysis of 11 trials found that pentoxifylline was more effective than placebo for complete healing or significant improvement in venous ulcers (RR 1.70; 95% CI, 1.30-2.24) 4
Pentoxifylline plus compression was more effective than placebo plus compression (RR 1.56; 95% CI, 1.14-2.13) 4, 6

Revascularization should be considered for patients with arterial leg ulcers who are ambulatory, have life expectancy >1 year, and can withstand surgical intervention 1
Medical therapies that might improve blood flow to meet resting metabolic needs of limb tissue would be desirable alternatives to surgical reconstruction, but currently no drug is approved for treatment of CLI 1
Parenteral administration of PGE-1 or iloprost for 7-28 days may be considered to reduce ischemic pain and facilitate ulcer healing in patients with CLI (Class IIb recommendation) 1
Oral iloprost is not effective for reducing amputation or death risk in CLI patients (Class III recommendation) 1

Determine if the patient has subclinical CLI (severely impaired distal perfusion without rest pain or ischemic ulcers) 1
Evaluate if the patient is a candidate for revascularization based on ambulatory status, life expectancy, and ability to withstand surgery 1
For patients who are candidates for revascularization: refer for lower extremity revascularization 1
For patients who are not candidates for revascularization: consider parenteral PGE-1 or iloprost (7-28 days) to reduce pain and facilitate healing 1
Avoid parenteral pentoxifylline as it has been shown not to be useful for CLI 1, 2