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Pentoxifylline (Oxpentifylline)

A Review of its Therapeutic Efficacy in the Management of Peripheral Vascular and Cerebrovascular Disorders

  • Drug Evaluation
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Summary

Synopsis

Pentoxifylline (oxpentifylline) has been used widely in the treatment of intermittent claudication, a prevalent condition in the elderly population. The exact mechanism(s) of action of the drug are unclear, but may be related to identified effects on white blood cell function and haemorrheological parameters. Clinical trials which conform best with European and North American guidelines have shown that 6 months’ oral therapy with pentoxifylline 1200 mg/day significantly improves walking distances in patients with intermittent claudication. Patients most likely to benefit from treatment are those with an ankle/arm blood pressure ratio ≤0.8 and a history of disease >1 year. However, it remains unclear whether pentoxifylline or any other conservative treatment approach (including physical training) offers long term benefit, as studies comparing the development of intermittent claudication after several years of treatment with the natural course of the disease are still lacking.

In patients with more severe vascular disease, intravenous administration of pentoxifylline (1200 mg/day for 21 days) decreased rest pain in patients with critical limb ischaemia. Oral administration (1200 mg/day for up to 6 months) increased the healing of venous ulcers of the leg when used as an adjunct to standard compression bandaging. However, further studies are required to confirm these initial findings.

The efficacy of pentoxifylline in the treatment of cerebrovascular disease has been evaluated in controlled clinical trials. Most notably, long term therapy (1200 mg/day) may slow the progression of dementia in patients who meet the clinical diagnostic criteria for ‘multi-infarct’ dementia and who also have clinical and neuroradiological evidence of cerebrovascular disease. The drug is effective in decreasing the risk of transient ischaemic attacks, but there are insufficient data to determine its value in the prevention and treatment of stroke.

Pentoxifylline is well tolerated, with gastrointestinal effects reported in fewer than 3% of treated patients. However, the incidence of adverse events may be higher in elderly patients and/or those receiving concomitant medications.

In summary, pentoxifylline is the most established agent when drug therapy is deemed appropriate in patients with intermittent claudication. Moreover, a promising new development for the drug is in the management of cerebrovascular dementia, an area where few therapeutic options are currently available.

Pharmacodynamic Properties

Oral and/or intravenous administration of pentoxifylline (oxpentifylline) improves indices of lower limb blood flow in patients with peripheral obliterative arterial disease (POAD) as well as regional and/or global cerebral blood flow in patients with chronic cerebrovascular disease. Notably, there is no evidence of the ‘steal’ phenomenon, with the greatest improvement in blood flow seen in the more ischaemic regions. However, the haemodynamic effect of the drug (increase in cerebral blood flow) has been observed to decrease with age in elderly patients with chronic cerebrovascular insufficiency.

The mechanism(s) of action of pentoxifylline have not been fully resolved. Like other methylxanthine derivatives, pentoxifylline causes smooth muscle to relax; however, the contribution of this effect to the overall activity of the drug is unclear. Several rheological properties have been identified which decrease blood viscosity and help improve perfusion in the impaired microcirculation. Early studies demonstrated that pentoxifylline causes an increase in the filterability of erythrocytes and neutrophils, decreased plasma fibrinogen levels and reduced platelet aggregation, but more recent studies suggest that effects on leucocytes, especially granulocytes, may be more important. Activation of leucocytes is implicated in some pathophysiological mechanisms of occlusive peripheral vascular disease. Pentoxifylline decreases neutrophil adhesiveness to endothelial cells, enhances chemotaxis, inhibits tissue necrosis factor and blocks the activity of inflammatory cytokines, which regulate the degree of activity of vascular wall cells.

Pharmacokinetic Properties

Thus far, the pharmacokinetic parameters of pentoxifylline have not been directly compared in young and older individuals. In healthy adult volunteers, peak plasma concentrations of pentoxifylline (0.3 mg/L) and its active metabolite hydroxy-pentoxifylline (0.34 mg/L) are reached about 3.2 hours after oral administration of a single 400mg sustained-release tablet. The oral bioavailability of pentoxifylline when administered as the sustained-release tablet is about 20%. Food and smoking reduce the plasma concentration of pentoxifylline and particularly that of its active metabolite hydroxy-pentoxifylline.

Pentoxifylline is extensively metabolised in erythrocytes and the liver, and is excreted primarily via the kidneys. After a single oral dose (400mg), plasma concentrations of the parent drug and hydroxy-pentoxifylline are essentially unaltered in patients with renal insufficiency, but increased in patients with hepatic disease (alcoholic cirrhosis). The plasma clearance of pentoxifylline was reduced and the elimination half-life of pentoxifylline and hydroxy-pentoxifylline prolonged significantly in patients with cirrhosis after intravenous administration of a single 100mg dose of the parent drug. The pharmacokinetics of pentoxifylline are largely unaffected after multiple-dose oral administration in patients with renal failure. However, comparable multi-dose data in patients with hepatic disease are currently unavailable.

Therapeutic Efficacy

Placebo-controlled studies which best conform with North American or European guidelines, have demonstrated that oral or intravenous administration of pentoxifylline 600 to 1200 mg/day significantly increases walking distances in patients with intermittent claudication. The beneficial effect of the drug has also been demonstrated when combined with an additional programme of physical exercise. In the most rigorous study to date, subgroup analysis identified a consistent and clear-cut effect of the drug in patients who had an ankle/arm blood pressure ratio ≤0.8 and history of disease >1 year.

Pentoxifylline has been compared with vasodilators [e.g. buphenine (nylidrin), buflomedil, nifedipine] and antithrombotic agents (e.g. defibrotide), but due to very small patient numbers and/or methodological deficiencies, results are inconclusive. There is some evidence that intravenous alprostadil (prostaglandin E1) may be superior to pentoxifylline. In elderly patients with critical leg ischaemia, intravenous administration of pentoxifylline (1200 mg/day for 21 days) significantly reduced pain symptoms compared with placebo.

According to the results of a population-based historical cohort study, treatment with full-dose pentoxifylline significantly reduces the number of invasive diagnostic measures and surgical interventions in patients with POAD during a 2-year follow-up period. However, it remains to be established in a prospective study whether pentoxifylline use avoids or merely postpones subsequent surgical procedures.

Oral administration of pentoxifylline 1200 mg/day as an adjunct to standard compression bandaging improved the healing of venous ulcers of the leg compared with placebo (64 vs 34%; n=80). However, the healing rate in the placebo group was lower than expected. Pentoxifylline 1200 mg/day, administered orally, was more effective than aspirin 1050 mg/day plus dipyridamole 150 mg/day in preventing cerebrovascular transient ischaemic attacks. However, neither regimen decreased the proportion of patients who progressed to stroke. In patients with acute non-haemorrhagic stroke, intravenous administration of pentoxifylline 1200mg/day initiated within 12 hours of symptom onset and continued for 3 days was beneficial compared with placebo. However, subsequent oral administration of the drug for 25 days was of little benefit. Nonetheless, intravenous infusion of 400 mg/day within 12 to 24 hours produced superior rehabilitation rates compared with a combination of hexobendine, etamivan and etofylline.

In placebo-controlled studies, long term oral therapy with pentoxifylline 1200 mg/day has been demonstrated to slow the progression of dementia in patients who meet DSM-III criteria for ‘multi-infarct’ dementia and have clinical and neuroradiological evidence of cerebrovascular disease. It is unclear whether patients with or without a history of one or more ischaemic episodes respond best to pentoxifylline.

Tolerability

Gastrointestinal symptoms are the most common complaint, occurring in about 3% of patients receiving therapeutic dosages of pentoxifylline (sustained-release tablets). According to the results of one small-scale analysis in adult patients with POAD (n=449), the tolerability of pentoxifylline was similar to that of placebo. However, discontinuation due to adverse events was necessary in 3 and 0%, respectively, of pentoxifylline and placebo recipients. The tolerability profile of pentoxifylline in patients with cerebrovascular disease appears similar to that in patients with peripheral vascular disease.

Coadministration of pentoxifylline with other commonly prescribed drugs (e.g. cimetidine and theophylline) appears to result in a higher incidence of adverse events. Furthermore, limited data suggest that elderly patients receiving concomitant medications may be more susceptible to the hypotensive effect of the drug, reflected in a decrease in elevated systolic (but not diastolic) blood pressure.

Dosage and Administration

The usual adult oral dosage of pentoxifylline is 1200mg daily in 3 divided doses with meals; however, this should be reduced to 800 mg/day in the event of poor gastrointestinal and/or CNS tolerability. Therapy should be maintained for at least 8 weeks. When required, pentoxifylline can be administered intravenously. Infusion of 100 mg/day up to a maximum of 1200 mg/day (in 50 to 100 mg/day increments) is normally recommended.

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    James E. Frampton & Rex N. Brogden

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Various sections of the manuscript reviewed by:R. Black, Burke Medical Research Institute, Dementia Research Service, White Plains, New York, USA; R.K. Campbell, College of Pharmacy, Washington State University, Pullman, Washington, USA; M.P. Colgan, Department of Vascular Surgery, St. James’ Hospital, Dublin, Ireland; E. Ernst, Centre for Complementary Health Studies, Postgraduate Medical School, University of Exeter, Exeter, England; F. Kuzuya, Nakatsugawa Municipal Hospital, Komanba, Nakatsugawa-shi, Gifu, Japan; F. Lindgärde, Department of Medicine, Malmö General Hospital, Malmö, Sweden; T. Loosemore, Department of Surgery, East Surrey Hospital, Redhill, Surrey, England; V.F. Mauro, College of Pharmacy, University of Toledo, Toledo, Ohio, USA; D.A. Shields, Department of Surgery, University College London Medical School, The Middlesex Hospital, London, England.

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Frampton, J.E., Brogden, R.N. Pentoxifylline (Oxpentifylline). Drugs & Aging 7, 480–503 (1995). https://doi.org/10.2165/00002512-199507060-00007

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