01Purpose and principlesWhat the treatment does and how it fits into care.
Structured walking is a core treatment for intermittent claudication. Repeated bouts of symptom-provoking exercise with recovery can improve walking performance and function even though the fixed arterial lesion may remain. A supervised programme also creates opportunities to correct technique, monitor safety, support smoking cessation and build confidence. Improvement should be judged by both measured walking and the activity the person wants to regain.
NICE recommends supervised exercise first and gives a programme example of two supervised hours each week for three months, encouraging exercise to the point of maximal pain. This applies to stable intermittent claudication in a suitable participant. It does not override acute limb ischaemia, chronic limb-threatening ischaemia, unstable cardiovascular disease, severe infection or unsafe falls risk. If an adequate programme remains unsatisfactory, reassess diagnosis, adherence, goals and prevention before choosing a selective symptom medicine or vascular referral.
Key points
- Offer a supervised exercise programme to all suitable people with intermittent claudication.
- NICE suggests two supervised hours weekly for three months, encouraging exercise to maximal claudication pain.
- Document baseline walking, patient goals, cardiovascular safety, feet and factors limiting participation.
- Combine supervised sessions with a sustainable home and community activity plan.
- Do not use pain-to-maximum walking for acute ischaemia, rest pain or tissue loss.
- Consider naftidrofuryl only after supervised exercise is unsatisfactory and revascularisation is not preferred.
- Review naftidrofuryl after three to six months and stop it without symptomatic benefit.
- Persistent lifestyle-limiting symptoms prompt shared vascular review, not serial ineffective medicines.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
Exertional muscle discomfort is reproducible, resolves with rest and is not accompanied by rest pain, tissue loss, acute neurological deficit or unstable systemic illness.
Record pain-free and maximum walking distance or time, usual pace, terrain, work and caregiving demands, participation limits and a personal functional goal.
Transport, employment, caring duties, fear of pain, low mood, language, cost, footwear, arthritis, neuropathy and cardiorespiratory limitation affect programme completion.
New exertional chest pain, syncope, unstable breathlessness or symptomatic arrhythmia requires clinical assessment before progressing exercise intensity.
Rest pain, ulceration, gangrene or sudden sensory or motor change requires urgent vascular assessment instead of routine claudication exercise.
Little improvement after a completed programme should trigger checks of diagnosis, training dose, technique, adherence, comorbid limitation and patient-valued outcome.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Baseline walking assessmentFirst step - Why
- Quantify symptom onset, maximum tolerance and functional change during the programme.
- Interpretation and limitations
- Use a reproducible corridor or treadmill protocol where available and record speed, gradient, pain onset, stopping point and reason for stopping. A real-world walking goal should accompany test distance because laboratory improvement may not restore participation.
- 02
Clinical cardiovascular and limb safety screen - Why
- Identify conditions requiring stabilisation, modification or a different urgent pathway.
- Interpretation and limitations
- Check symptoms, observations, rhythm concerns, falls, footwear, skin, wounds, pulses and neuropathy. Stable cardiovascular disease commonly benefits from exercise, while acute coronary symptoms, decompensation, acute limb ischaemia or limb threat requires assessment before training.
- 03
ABPI and Doppler waveform review - Why
- Confirm the PAD context and detect discordant or unreliable resting physiology.
- Interpretation and limitations
- A low index supports PAD, but normal or raised ABPI does not exclude disease in diabetes or calcification. Waveforms, toe pressure or specialist testing can clarify discordance; repeated ABPI is not required before every exercise session.
- 04
Medicine and comorbidity review - Why
- Find treatment, adverse effects or other disease that limits safe exercise.
- Interpretation and limitations
- Review antihypertensives, rate-limiting drugs, antithrombotics, hypoglycaemia risk, anaemia, pulmonary disease and musculoskeletal pain. Modify the plan around the actual limitation rather than assuming persistent walking difficulty is all arterial.
- 05
Post-programme outcome assessment - Why
- Determine whether walking, symptoms and the chosen functional goal improved sufficiently.
- Interpretation and limitations
- Compare like with like for pain-free and maximum walking, adverse events and goal attainment. An unsatisfactory response does not by itself prove more severe anatomy; confirm completion, diagnosis and other limitations before medicine or revascularisation decisions.
04Treatment approachPreparation, options, escalation and aftercare.
01Supervised exercise programmeDeliver a safe three-month walking interventionFirst stepStable intermittent claudication limits walking and the safety screen identifies no reason for urgent or stabilising treatment.+
- 1Agree a personal walking goal and record reproducible baseline pain-free and maximum walking measures, foot status and cardiovascular symptoms.
- 2Offer approximately two hours of supervised exercise each week for three months, divided into practical sessions by the delivering service.
- 3Within sessions, alternate walking that provokes claudication up to maximal pain with rest sufficient for symptoms to settle, then repeat under supervision.
- 4Progress speed, gradient or walking duration according to response while checking chest symptoms, breathlessness, dizziness, gait, skin and footwear.
- 5Build a home and community plan between sessions, address smoking and prevention, and adapt around arthritis, neuropathy or disability without losing training intent.
- 6At completion, compare walking and the personal goal, record safety outcomes, and agree maintenance activity or further vascular review.
02Adapted participation pathwayPreserve training when standard walking is difficultComorbidity, disability, transport or social barriers prevent attendance or safe standard treadmill walking.+
- 1Identify whether the barrier is medical instability, musculoskeletal pain, balance, neuropathy, communication, travel, work or caring responsibility.
- 2Stabilise urgent medical problems and use the supervised team to select safe interval walking or another locally supported exercise mode.
- 3Set an equivalent progressive workload and measurable goal, with foot checks and falls precautions suited to the individual.
- 4Review participation early and alter session timing, support or referral rather than allowing silent programme dropout.
03Unsatisfactory responseReassess before escalating symptom treatmentEscalationAn adequate supervised programme has not delivered a satisfactory improvement in symptoms or valued function.+
- 1Confirm attendance, exercise intensity, home activity and whether arterial pain actually caused the stopping limitation.
- 2Revisit ABPI reliability, spinal or joint disease, anaemia, heart or lung disease, depression and patient expectations.
- 3If the person prefers not to pursue revascularisation, consider naftidrofuryl within NICE criteria and licensed product dosing.
- 4If symptoms remain severely lifestyle limiting despite appropriate management, discuss vascular referral and anatomical imaging only when revascularisation is being considered.
04Naftidrofuryl reviewContinue only measurable symptom benefitNaftidrofuryl was started after inadequate supervised exercise and a decision not to pursue revascularisation.+
- 1Record baseline walking and chosen functional outcome, confirm licensed dose, contraindications, hydration advice and anticipated gastrointestinal effects.
- 2Review between three and six months using symptoms, walking, adherence and adverse effects rather than prescription collection alone.
- 3Stop naftidrofuryl when no symptomatic benefit is evident, and reconsider diagnosis, maintenance exercise and vascular referral according to disability and preference.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Naftidrofuryl oxalate (Accord 100 mg capsules)
The Accord product uses one or two 100 mg capsules orally three times daily, during or after food with a glass of water, for at least three months unless the clinician changes the plan. Apply NICE review at three to six months and stop if symptoms do not improve.Do not use with previous hyperoxaluria or recurrent calcium-containing kidney stones. Maintain adequate fluid intake and take capsules with water to reduce stone and oesophagitis risks. Stop for symptoms suggesting liver damage; avoid during pregnancy and do not use while breastfeeding.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Record supervised attendance, exercise dose, pain-free and maximum walking, adverse symptoms and the reason each session ends.
- Inspect feet and footwear regularly, especially with diabetes, neuropathy, deformity, a previous ulcer or a new blister.
- Review the chosen real-world activity goal at programme completion and during maintenance planning.
- Continue smoking, lipid, blood-pressure, diabetes and antithrombotic review because exercise does not replace cardiovascular prevention.
- For naftidrofuryl, reassess symptoms and walking at three to six months and discontinue treatment if no benefit is evident.
- Safety-net for sudden deterioration, rest pain, tissue loss, chest pain, syncope or unstable breathlessness.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Pain has a therapeutic role
For stable claudication, supervised intervals deliberately provoke symptoms and NICE encourages exercise to maximal pain; the rest phase permits repeated training bouts.
Programme dose needs interpretation
NICE describes two supervised hours weekly for three months, while the delivering service may divide this into different session lengths without changing the total supervised intent.
Exercise is broader than a treadmill
Walking remains the most direct claudication training, but disability or joint disease may require specialist adaptation that preserves progressive aerobic work and measurable goals.
Naftidrofuryl is conditional
It follows an unsatisfactory supervised exercise response and a preference against revascularisation; it is not a shortcut around exercise or an indefinite unmeasured prescription.
NICE excludes several alternatives
CG147 says not to offer cilostazol, pentoxifylline or inositol nicotinate for intermittent claudication, keeping naftidrofuryl as the selected drug option under its criteria.
08Common pitfallsFrequent interpretation and management errors.
- 01
Giving generic walk more advice without referral to a structured supervised programme or a measurable progression plan.
- 02
Applying pain-to-maximum exercise to acute limb ischaemia, rest pain, tissue loss or unstable cardiovascular disease.
- 03
Judging response only by ABPI, which may remain unchanged while walking capacity and quality of life improve.
- 04
Starting naftidrofuryl before an adequate supervised exercise attempt or without documenting preference about revascularisation.
- 05
Continuing naftidrofuryl indefinitely without a three-to-six-month assessment of actual symptomatic benefit.
- 06
Referring for anatomical imaging automatically after programme completion without confirming lifestyle-limiting symptoms and treatment intent.