## Pharmacological Management of Critical Limb Ischaemia ### Clinical Context Critical limb ischaemia (CLI) represents the most severe form of PAD, characterized by: - Rest pain (pain at rest, especially nocturnal) - Tissue loss (ulcers, gangrene) - High amputation risk if revascularization is not possible **Key Point:** Iloprost, a prostacyclin analogue, is the evidence-based pharmacological agent for symptomatic CLI when revascularization is not feasible, with proven benefit in reducing amputation rates and promoting ulcer healing. ### Iloprost: Mechanism & Evidence | Property | Details | |----------|----------| | **Class** | Prostacyclin analogue (PGI₂ mimetic) | | **MOA** | Vasodilation, antiplatelet, anti-inflammatory, improves microcirculation | | **Route** | Intravenous infusion (6 hours/day for 28 days) | | **Evidence** | Reduces amputation risk by ~30% in CLI; promotes ulcer healing | | **Onset** | 2–4 weeks for symptomatic benefit | ### Dosing Protocol - Initial: 0.5 ng/kg/min IV infusion - Titrate up to 2 ng/kg/min over 30 minutes - Continue for 6 hours daily - Typical course: 28 days (can repeat if needed) **High-Yield:** Iloprost is specifically indicated for CLI with tissue loss when revascularization is not possible. It is the only pharmacological agent with proven amputation-reduction benefit in this setting. [cite:Harrison 21e Ch 244] **Clinical Pearl:** Iloprost is administered as an inpatient infusion and requires careful hemodynamic monitoring. Common side effects include headache, jaw claudication, and hypotension — these are usually manageable and do not require discontinuation. **Mnemonic:** **ILOPROST** = **I**nfusion for **L**imb-threatening **O**cclusion, **P**rostacyclin-based, **R**educes **A**mputation, **S**aves **T**issue.
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