How should I manage a patient with intermittent claudication who is not responding to lifestyle modifications?

Management of a patient with intermittent claudication not responding to lifestyle modifications:

• Offer a supervised exercise programme if not already done, typically 2 hours per week for 3 months, encouraging exercise to the point of maximal pain.
• If supervised exercise is unavailable or declined, consider advising unsupervised exercise such as walking for 30 minutes three to five times per week, walking until symptoms develop then resting to recover.
• Reinforce advice on modifying cardiovascular risk factors including smoking cessation, diet, weight management, control of diabetes, hypertension, and lipid modification.
• If symptoms do not improve satisfactorily after supervised exercise and risk factor modification, consider referral for imaging and assessment for angioplasty or bypass surgery, provided the patient is suitable for revascularisation.
• If the patient prefers not to undergo revascularisation, consider pharmacological treatment with naftidrofuryl oxalate, reviewing progress after 3–6 months and discontinuing if no benefit is observed.
• Provide tailored information about the condition, risks, treatment options, and support for psychological aspects such as depression and anxiety.

This approach aligns with NICE guidelines and other international recommendations for managing intermittent claudication in peripheral arterial disease NICE CKS,NICE CG147.