The next step is to determine if the patient has diabetes according to current guidelines. Treatment for patients with diabetes should be guided by diabetes guidelines but some considerations extend to patients with PAD.
Patients with diabetes should have glucose-lowering therapy to reduce their risk of microvascular complications including renal disease and retinopathy. In addition, newer target-specific therapies have shown benefits in patients with cardiovascular disease. The GLP-1 agonist liraglutide was shown to reduce ischemic MACE in patients with diabetes. Inhibitors of SGLT2 have been shown to reduce cardiovascular death and heart failure in patients with atherosclerosis including PAD. These therapies should be considered as recommended by current guidelines. Partnering with a local diabetes specialist may be helpful in targeting intensive therapies for the complex and high-risk population with PAD and diabetes.
Specific consideration should be given when prescribing an SGLT2 inhibitor. The agent, canagliflozin, was shown to be associated with an increased risk of amputation with the greatest risk in those with PAD and particularly those with prior amputation. Until these data and the related mechanisms are better understood, caution should be exercised when prescribing canagliflozin to this population and if using an SGLT2 inhibitor, an agent that has not been shown to have this risk would be preferred.