Cilostazol

How it works

By inhibiting phosphodiesterase III it raises intracellular cyclic AMP, producing vasodilatation and inhibition of platelet aggregation, which improves peripheral blood flow.

Prescribing in practice

• Cilostazol is contraindicated in heart failure of any severity because other phosphodiesterase III inhibitors increase mortality in this group.
• It is metabolised by CYP3A4 and CYP2C19, so doses are reduced with potent inhibitors such as certain macrolides, azoles and omeprazole.
• Avoid in those with predisposition to bleeding and review combined use with antiplatelets or anticoagulants.

Monitoring

Review symptomatic benefit on walking distance after the early weeks of treatment and stop if there is no worthwhile improvement, while watching for palpitations and bleeding.

Counselling the patient

• Take it on an empty stomach, before food in the morning and evening.
• Headache, palpitations and diarrhoea are common early on and often settle.
• Stop and seek advice if you develop breathlessness or ankle swelling.

Evidence & guidelines

NICE recommends cilostazol as an option for claudication based on trials showing modest improvements in pain-free and maximal walking distance versus placebo.