Beyond the Rx: How Pharmacists Fill an Important Role in Prevention, Treatment of Peripheral Artery Disease

When discussing cardiovascular (CV) disease, there is a common misconception that it’s solely related to the heart. However, as health care professionals, we know that CV disease actually refers to several conditions that can affect more than just this single organ.¹

One of these conditions is peripheral artery disease (PAD), the lesser-known CV disease that causes the blood vessels to narrow, commonly reducing blood flow to the legs.² One of the factors that has driven me in my career as a pharmacist is my personal connection to CV disease and witnessing how it has affected several of those closest to me. My late grandfather underwent a triple bypass, my father has atrial flutter, and my uncle lives with atrial fibrillation.

While in graduate school and as a licensed pharmacist, I’ve spent years helping my loved ones untangle the myths and misconceptions surrounding CV disease—often serving as mediator between my family members, their physicians, and surgeons. These experiences have allowed me to observe firsthand the unnecessary and avoidable impact that these complexities can have on those living with a chronic illness.

When it comes to PAD, there is no shortage of these complexities. Often unknown, unseen, and undertreated³—as few as one-third of individuals who are living with PAD are receiving medical therapies to address their risk factors⁴—PAD is associated with potentially serious health outcomes.²

Among those are heart attack, stroke, acute limb ischemia, and even amputation,² a devastating complication of PAD that—despite being largely preventable—is associated with a high mortality rate.⁵

Seventy percent of patients with PAD who have a leg amputation die within 3 years.⁶ What’s more startling is that more than 400 amputations take place in the United States each day.⁵

Tragically, we know that Black Americans are up to 4 times more likely than white Americans to have a PAD-related amputation.⁷ This is because of systemic barriers, such as less access to quality vascular care,⁵ greater risk for delays in care,⁸ and increased cases of PAD in Black communities that often go unaddressed until it is simply too late.⁹

So, what can we do to change these statistics?

As associate director of Health Equity at Janssen Cardiovascular and Metabolism Medical Affairs, I’ve seen firsthand the steps being made by our company to support those placed at high risk of PAD, particularly among the Black community. This year, Janssen launched the multiyear Save Legs. Change Lives.™ initiative that is focused on helping those at risk of PAD-related amputations through more than 12 programs across 3 focus areas: empowering individuals and communities placed at an increased risk of PAD, collaborating with powerful partners, and driving research.

Although initiatives such as these are important, it will take the full effort of the entire health care community to affect real change in this space, and everyone has a role to play. It starts with health care providers, and pharmacists are no exception.

In fact, pharmacists can—and should—play a significant role in the early treatment and prevention of PAD. Here are 3 ways I believe we can:

1. Become a PAD champion

The numbers tell us that PAD should not be overlooked: Upwards of 42% of coronary artery disease (CAD) patients also have PAD.¹⁰ But even as health care providers, we live in a world of curation versus information—where much of the information being circulated is still focused on coronary disease, and other forms of vascular disease get glossed over (I know this, having attended 6 years of pharmacy school, where I spent a short period of time learning about PAD).

This information void is what ultimately leads to errors such as misdiagnosis of PAD, e.g., the disease commonly mistaken for neuropathy. All health care providers, including pharmacists, have a responsibility to patients to be knowledgeable in all diseases and subtypes, especially conditions such as PAD that are associated with high morbidity rates.

Let’s take matters into our own hands. Learn the signs, symptoms, and risk factors, and equip yourself to recognize them in patients.

2. Serve as a gateway provider

As pharmacists, we have the unique privilege of seeing patients through various health events, provider changes, and treatments—as well as frequently hearing about new symptoms before their primary care physicians (PCPs). It isn’t uncommon for us to have a more complete knowledge of patients’ medical history than their PCPs, enabling us to serve as a gateway to medical counsel, and the first line of defense on their care teams.

If we can harness this holistic knowledge of our patients with an acute understanding of PAD, we can position ourselves to recognize the disease and help the patient apprehend it before it results in a negative health outcome, such as amputation.

To demonstrate how this looks in action, treatment changes or additions should be among the biggest alerts to ask questions. For example, if a patient suffering from diabetes and CV disease who has been on a statin for years comes in with a new prescription for a pain medicine to treat the lower leg—and we know that leg pain is one of the preeminent symptoms of PAD¹¹—a next step might be to have the patient monitor the pain and recommend a PAD screening if symptoms continue.

Ask questions and don’t be afraid to assign homework when you notice that something is off.

3. Get proactive about prevention: Drive screenings

A common PAD screening—the ankle-brachial index (ABI) test—is far less invasive than a colonoscopy, mammogram, and many other tests that have been standardized for individuals in certain risk categories (age, gender, etc), and yet, we don’t think to administer the test until after symptoms arise.¹²

Why? Let’s consider changing this approach.

We should be aware of the risk factors that contribute to PAD—age, race, diabetes, among others^9,11,13 —so internalize these risk categories and proactively recommend screenings to patients who fall within them. Have a list of area providers or locations that provide PAD screenings on hand and be ready with a recommendation if you believe a patient is at risk. Resources such as Save Legs. Change Lives.^TM provide free, non-invasive ABI tests in cities around the United States.

Additionally, you may consider whether your place of work can be equipped to provide PAD screenings—organize a screening event and get the word out in your community.

As stated previously, reducing the impact of PAD will require certain systematic changes to how the disease is approached by the medical community as a whole. Putting more emphasis on PAD in medical school, at conferences, and in future studies—and dedicating more time to the study of its signs, symptoms, and risk factors—will ultimately change how it is viewed and prioritized in pharmacies and physicians’ offices.

There is more work to be done, but we are moving in the right direction. I’m proud to be a part of organizations that are imparting change in CV disease, and although initiatives such as these are necessary to drive health equity in PAD care, it’s going to take the full breadth of the health care community to diminish these statistics in the Black community, and beyond.

As health care providers, it starts with us.

Visit SaveLegsChangeLives.com for information and resources that you can share with your patients to help start a dialogue about PAD.

References

1. Cleveland Clinic. Cardiovascular Disease. Accessed December 5, 2022 from https://my.clevelandclinic.org/health/diseases/21493-cardiovascular-disease
2. National Heart, Lung, and Blood Institute. Peripheral Artery Disease. Accessed December 5, 2022 from https://www.nhlbi.nih.gov/health-topics/peripheral-artery-disease
3. Afzal N, Sohn S, et al. Surveillance of Peripheral Arterial Disease Cases Using Natural Language Processing of Clinical Notes. AMIA Jt Summits Transl Sci Proc. 2017;2017:28-36.
4. Hirsch AT, Criqui MH, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286(11):1317-1324. doi:10.1001/jama.286.11.1317
5. Creager MA, Matsushita K, et al. Reducing nontraumatic lower-extremity amputations by 20% by 2030: time to get to our feet: a policy statement from the American Heart Association. Circulation. 2021;143(17):e875-e891. doi:10.1161/CIR.0000000000000967
6. Jones WS, Patel M, et al. High mortality risks after major lower extremity amputation in Medicare patients with peripheral artery disease. Am Heart J. 2013 May;165(5):809-815, 815.e1. doi:10.1016/j.ahj.2012.12.002.
7. Holman KH, Henke PK, et al. Racial disparities in the use of revascularization before leg amputation in Medicare patients. J Vasc Surg. 2011;54(2):420-426.
8. Winta G, Tracie CC. African Americans and Peripheral Arterial Disease: A Review Article. International Scholarly Research Notices. 2012;2012:1-9. doi.org/10.5402/2012/165653
9. National Heart, Lung, and Blood Institute. Facts About Peripheral Arterial Disease (P.A.D.) for African Americans. Accessed December 5, 2022 from https://www.nhlbi.nih.gov/files/docs/public/heart/pad_extfactsheet_aa_508.pdf
10. American College of Cardiology. Peripheral Matters | Peripheral and Coronary Artery Disease: Two Sides of the Same Coin. Accessed December 5, 2022 from https://www.acc.org/latest-in-cardiology/articles/2019/09/14/24/42/peripheral-and-coronary-artery-disease-two-sides-of-the-same-coin#:~:text=Coronary%20artery%20disease%20(CAD)%20remains,peripheral%20artery%20disease%20(PAD).&text=As%20PAD%20affects%20an%20estimated,the%20population%20has%20both%20conditions.
11. Mayo Clinic. Peripheral Artery Disease (PAD). Accessed December 5, 2022 from https://www.mayoclinic.org/diseases-conditions/peripheral-artery-disease/symptoms-causes/syc-20350557?p=1
12. Mayo Clinic. Ankle-Branchial Index. Accessed December 5, 2022 from https://www.mayoclinic.org/tests-procedures/ankle-brachial-index/about/pac-20392934
13. Olin JW, Sealove BA. Peripheral Artery Disease: Current Insight Into the Disease and Its Diagnosis and Management. Mayo Clinic Proceedings. 2010;85(7):678-692. doi:10.4065/mcp.2010.0133