Intermittent Claudication

Intermittent claudication is pain in the legs caused by atherosclerosis (hardening of the arteries) of the lower extremities. Because atherosclerosis decreases the supply of blood and oxygen to the legs, people with intermittent claudication experience leg pain after walking a certain distance. People with this condition should be monitored by a doctor. The natural treatments for intermittent claudication include many of the same as those for atherosclerosis; these include controlling high cholesterol, modifying dietary and lifestyle factors that might influence atherosclerosis, and taking various nutritional supplements and herbs.

After reading this article, refer to the atherosclerosis article for more information about dietary changes that might favorably influence hardening of the arteries or the risk of heart disease associated with it. What follows is a discussion limited to those aspects of lifestyle and natural medicine that have been studied specifically in relation to intermittent claudication.

Checklist for Intermittent Claudication

Rating Nutritional Supplements Herbs
3Stars Inositol hexaniacinate (vitamin B3)
Propionyl-L-carnitine
Vitamin E		 Ginkgo biloba
2Stars Arginine (intravenous only)
L-carnitine		 Garlic
Padma 28
1Star Evening primrose oil
Magnesium		  
3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star An herb is primarily supported by traditional use, or the herb or supplement has little scientific support and/or minimal health benefit.

What are the symptoms of intermittent claudication? Initial symptoms of intermittent claudication are pain, aching, cramping, or fatigue of the muscles in the lower limbs that develop during walking and are quickly relieved by rest. Symptoms typically occur in the calf but may also be located in the foot, thigh, hip, or buttocks. In more advanced stages, the painful symptoms are present even at rest and are worsened by elevating the legs.

How is it treated? Antiplatelet and cholesterol-lowering drugs are generally prescribed in combination with anti-claudication medications, such as cilostazol (Pletal®) and pentoxifylline (Trental®). Exercise rehabilitation therapy, weight loss, and smoking cessation are often recommended. Surgical options to restore blood supply, called “revascularization” procedures, are usually reserved for those with progressive or disabling symptoms.

Dietary changes that may be helpful: Important dietary changes for preventing atherosclerosis (and, consequently, intermittent claudication) include avoiding meat and dairy fat, increasing fiber, and possibly avoiding foods containing trans fatty acids.

Lifestyle changes that may be helpful: Smoking is directly linked to intermittent claudication.1 2 People who have intermittent claudication or wish to prevent it should not smoke.

Although exercise may be helpful in the treatment of intermittent claudication, it is important for all people with this condition to consult a healthcare practitioner before beginning an exercise program.3 4

Nutritional supplements that may be helpful: Vitamin E supplementation has been shown in controlled trials to increase both walking distance and blood flow through arteries of the lower legs in people with intermittent claudication.5 6 Increasing dietary intake of vitamin E was also associated with better blood flow to the legs.7 Some early studies did not find vitamin E useful. Possibly this failure was due to the short duration of the studies,8 as one review article suggested that a minimum of four to six months of vitamin E supplementation may be necessary before significant improvement is seen.9 Most clinical trials of vitamin E and intermittent claudication used 400 to 600 IU per day, although one study used 2,400 IU per day.

In double-blind trials, supplementation with either L-carnitine and propionyl-L-carnitine (a form of L-carnitine) has increased walking distance in people with intermittent claudication. Walking distance was 75% greater after three weeks of L-carnitine supplementation (2 grams taken twice per day), than after supplementation with a placebo, a statistically significant difference.10 In the study using propionyl-L-carnitine, improvement occurred only in those who could not walk 250 meters to begin with. In that group, maximum walking distance increased by 78% with propionyl-L-carnitine supplementation compared with a 44% increase in the placebo group, also a statistically significant difference.11 The amount of propionyl-L-carnitine used was 1 gram per day, increasing to 2 grams per day after two months, and 3 grams per day after an additional two months, if needed. The results of this trial have been confirmed in a large European trial.12

Inositol hexaniacinate (IHN), a special form of vitamin B3, has been used successfully to treat intermittent claudication. The alleged advantage of IHN over niacin (another form of vitamin B3) is a lower risk of toxicity. A double-blind trial explored the effect of 2 grams of IHN taken twice per day for three months.13 In nonsmokers and in people with unchanged smoking habits, the increase in walking distance was significantly greater in the IHN group than in the placebo group. Other double-blind research has confirmed IHN’s ability to improve symptoms of intermittent claudication compared with placebo.14 This treatment should be monitored by a doctor.

Intravenous injections of the amino acid arginine have been shown to be remarkably effective at improving intermittent claudication. In a double-blind trial, 8 grams of arginine, injected twice daily for three weeks, improved pain-free walking distance by 230% and absolute walking distance by 155%, compared to no improvement with placebo.15 To date, no trials have examined the effects of oral arginine supplementation on intermittent claudication.

Magnesium may increase blood flow by helping to dilate blood vessels. A preliminary trial found that magnesium supplementation may increase walking distance in people with intermittent claudication.16 Many doctors suggest that people with atherosclerosis, including those with intermittent claudication, take approximately 250 to 400 mg of magnesium per day.

In a preliminary trial, supplementing with evening primrose oil (approximately 1,600 mg per day) led to a 10% increase in exercise tolerance in people with intermittent claudication.17

Caution: One study showed a slightly increased risk of vascular surgery among people with intermittent claudication who took beta-carotene supplements.18 Until more is known, people with intermittent claudication wishing to use beta-carotene supplements should first consult with their doctor.

Are there any side effects or interactions? Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful: Extensive studies have been done with Ginkgo biloba extracts (GBE) for treatment of intermittent claudication.19 20 Two double-blind trials found that 120 mg of GBE per day increased pain-free and total walking distance among people with intermittent claudication.21 22 Similar results were seen in another double-blind trial using 160 mg of GBE per day.23 In yet another double-blind trial, two doses of ginkgo extract were compared for six months.24 The researchers studied 60 vs. 120 mg twice daily and found that, while both amounts resulted in significant improvements in pain-free walking distance, the improvements were more pronounced at the higher dose.

A standardized extract of garlic has been tested as a treatment for intermittent claudication. In a double-blind trial, the increase in walking distance was significantly greater in people receiving garlic powder extract (400 mg twice per day for 12 weeks) than in those given a placebo.25

In a double-blind trial, people with intermittent claudication received 760 mg twice daily of the Tibetan herbal formula Padma 28® or a placebo for 16 weeks. The average walking distance increased by 115% among people receiving Padma 28, compared with a 17% increase in the placebo group (a statistically significant difference). No side effects were reported.26 Padma 28 was also found to increase walking distance in a second study.27

Are there any side effects or interactions? Refer to the individual herb for information about any side effects or interactions.

References:

1. Cahan MA, Montgomery P, Otis RB, et al. The effect of cigarette smoking status on six-minute walk distance in patients with intermittent claudication. Angiology 1999;50:537–46.

2. Gardner AW, Womack CJ, Montgomery PS, et al. Cigarette smoking shortens the duration of daily leisure time physical activity in patients with intermittent claudication. J Cardiopulm Rehabil 1999;19:43–51.

3. Walker RD, Nawaz S, Wilkinson CH, et al. Influence of upper- and lower-limb exercise training on cardiovascular function and walking distances in patients with intermittent claudication. J Vasc Surg 2000;31:662–9.

4. Gardner AW, Katzel LI, Sorkin JD, et al. Improved functional outcomes following exercise rehabilitation in patients with intermittent claudication. J Gerontol A Biol Sci Med Sci 2000;55:M570–7.

5. Haeger K. Long-time treatment of intermittent claudication with vitamin E. Am J Clin Nutr 1974;27:1179–81.

6. Williams HT, Fenna D, Macbeth RA. Alpha tocopherol in the treatment of intermittent claudication. Surg Gynecol Obstet 1971;Apr:662–6.

7. Donnan PT, Thomson M, Fowkes GR, et al. Diet as a risk factor for peripheral arterial disease in the general population: the Edinburgh Artery Study. Am J Clin Nutr 1993;57:917–21.

8. Livingstone PD, Jones C. Treatment of intermittent claudication with vitamin E. Lancet 1958;ii:602–4 [review].

9. Piesse JW. Vitamin E and peripheral vascular disease. Int Clin Nutr Rev 1984;4:178–82 [review].

10. Brevetti G, Chiariello M, Ferulano G, et al. Increases in walking distance in patients with peripheral vascular disease treated with L-carnitine: a double-blind, cross-over study. Circulation 1988;77:767–73.

11. Brevetti G, Perna S, Sabba C, et al. Effect of propionyl-L-carnitine on quality of life in intermittent claudication. Am J Cardiol 1997;79:777–80.

12. Brevetti G, Diehm C, Lambert D. European multicenter study on propionyl-L-carnitine in intermittent claudication. J Am Coll Cardiol 1999;34:1618–24.

13. Kiff RS, Wuick CRG. Does inositol nicotinate (Hexopal) influence intermittent claudication?—a controlled trial. Br J Clin Pract 1988;42:141–5.

14. O’Hara J, Jolly PN, Nicol CG. The therapeutic efficacy of inositol nicotinate (Hexopal) in intermittent claudication: a controlled trial. Br J Clin Pract 1988;42:377–83.

15. Boger RH, Bode-Boger SM, Thiele W, et al. Restoring vascular nitric oxide formation by L-arginine improves the symptoms of intermittent claudication in patients with peripheral arterial occlusive disease. J Am Coll Cardiol 1998;32:1336–44.

16. Neglen P, Overfordt P, Eklof B. Peroral magnesium hydroxide therapy and intermittent claudication. Vasa 1985;14:285–8.

17. Christie SB, Conway N, Pearson HE. Observations on the performance of a standard exercise test by claudicants taking gamma-linolenic acid. J Atheroscler Res 1968;8:83–90.

18. Törnwall ME, Virtamo J, Haukka JK, et al. The effect of alpha-tocopherol and beta-carotene supplementation on symptoms and progression of intermittent claudication in a controlled trial. Atherosclerosis 1999;147:193–7.

19. Schneider B. Ginkgo biloba extract in peripheral arterial disease. Meta-analysis of controlled clinical trials. Arzneimittelforschung 1992;42:428–36 [in German].

20. Peters H, Kieser M, Hölscher U. Demonstration of the efficacy of Ginkgo biloba special extract EGb 761® on intermittent claudication—a placebo-controlled, double-blind multicenter trial. VASA 1998;27:106–10.

21. Bauer U. Six-month double-blind randomised clinical trial of Ginkgo biloba extract versus placebo in two parallel groups in patients suffering from peripheral arterial insufficiency. Arzneimittelforsschung 1984;34:716–20 [in German].

22. Blume J, Kieser M, Hölscher U. Placebo-controlled, double-blind study on the efficacy of Ginkgo biloba special extract EGb 761 in maximum-level trained patients with intermittent claudication. Vasa 1996;25:265–74.

23. Blume J, Kieser M, Hölscher U. Efficacy of Ginkgo biloba special extract EGb 761 in peripheral occlusive disease. Fortschr Med 1998;116:137–43.

24. Schweizer J, Hautmann C. Comparison of two dosages of Ginkgo biloba extract EGb 761 in patients with peripheral arterial occlusive disease Fontaine’s stage IIb. Arzneimittelforschung 1999;49:900–4.

25. Kiesewetter H, Jung F, Jung EM, et al. Effects of garlic coated tablets in peripheral arterial occlusive disease. Clin Investig 1993;71:383–6.

26. Smulski HS, Wojcicki J. Placebo-controlled, double-blind trial to determine the efficacy of the Tibetan plant preparation Padma 28 for intermittent claudication. Altern Ther 1995;1(3):44–9.

27. Drabaek H, Mehlsen J, Himmelstrup H, Winther K. A botanical compound, Padma 28, increases walking distance in stable intermittent claudication. Angiology 1993;44:863–7.