Russian clinical recommendations for the treatment of venous diseases: pharmacotherapy

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Thanks to the author - Marina Kuznetsova Today we will talk about venotonics:

• What are they doing?
• What is the difference between Detralex and Phlebodia?
• Advantages of the drug Detralex.
• What should the buyer be warned about when selling venotonic?
• What is the difference between Venarus and Detralex?
• What is the difference between Phlebaven and Detralex?
• When is it optimal to offer a drug based on diosmin alone?
• What questions should the buyer ask?
• How to take venotonic drugs correctly?
• Features of some popular external venotonics.

Go!

First, let's recap a few basic things you need to know.

First. People are not born with varicose veins. There are congenital anomalies of the venous system, but this is very rare. The problem appears at the age of 18. Therefore, these drugs are prescribed, as a rule, also at the age of 18.

Second. If your mother, grandmother, or great-grandmother had varicose veins, then, most likely, one bad guy got into the set of genes, who is guilty of violating the ratio of collagen and elastin proteins in the venous wall. Yes, yes, don't be surprised. These proteins are not only found in the skin. And they, as you know, are responsible for strength and elasticity, i.e. the ability of the venous wall to return to its original state after stretching.

Third. Veins have venous valves that open and close. They are needed so that the blood in the veins flows strictly from bottom to top.

Fourth. The venous wall contains muscle fibers that, by contracting, help move blood.

Fifth. The veins really like it when we walk, and really don’t like it when we sit or stand most of the day. When we walk, the muscles of the legs work, compress the veins passing through them and, like a pump, pump blood upward. And when we sit or stand, blood runs through the veins reluctantly. Relative blood stagnation occurs. The pressure in the veins increases, the blood puts pressure on the venous walls, and they begin to stretch. The diameter of the veins increases, and the venous valves can no longer close. As a result, blood flows both up and down. The reverse flow of blood due to venous disease is called venous reflux.

Sixth. As a result of dilation of the veins and stagnation of blood, the permeability of their walls increases, the liquid part of the blood enters the intercellular space (hence the swelling and heaviness in the legs) and compresses small vessels - capillaries, through which oxygen and nutrients are exchanged between the blood and surrounding tissues. Microcirculation is disrupted, i.e. this very exchange. The tissues of the legs begin to experience oxygen starvation.

Seventh. Without receiving sufficient nutrition, some of the collagen and elastin fibers in the venous wall die. The vein wall becomes thinner and loses its elasticity.

Eighth. Under conditions of oxygen deficiency, endothelial cells of the venous wall begin to produce inflammatory mediators. They increase the “stickiness” of leukocytes to the venous wall, destroy its collagen fibers, and promote the formation of free radicals, which begin to destroy everything around.

5.2. Pharmacological drugs used in the treatment of chronic venous disease

The means of basic pharmacotherapy for chronic venous disease are phlebotropic drugs (synonyms: FLP, venoactive drugs, phleboprotectors, venotonics), which represent a heterogeneous group of biologically active substances obtained by processing plant raw materials or chemical synthesis, united by the ability to increase venous tone, as well as reduce the severity of venous -specific symptoms and syndromes.

The classification of the main phlebotropic drugs is presented in Table 5.

Table 5. Classification of main phlebotropic drugs

5.3. Mechanism of action of phlebotropic drugs

Phlebotropic drugs increase the tone of peripheral veins and lymphatic vessels due to their effect on the norepinephrine-dependent mechanism, as well as due to some drug-specific effects (Table 6).

Table 6. Therapeutic effects and mechanisms of action of phlebotropic drugs

What are venotonics?

Venotonics (phlebotonics) are drugs that improve the condition of the vascular wall.

They have two main effects:

Venotonic – increase tone, i.e. tension of the venous wall, and due to this they reduce the distensibility of the veins and prevent stagnation of blood in the veins.

Angioprotective - increase the resistance of capillaries to damage, improve microcirculation, and therefore nutrition of the vascular wall.

Venotonic drugs are used mainly for venous diseases and for the treatment of acute hemorrhoids, because in this case, the venous outflow is also impaired, but only through the veins of the rectum.

5.4. Clinical effectiveness of phlebotropic drugs

The main indication for the use of phlebotropic drugs are symptoms associated with CVD: heaviness in the legs, discomfort, itching, pain along the varicose veins, paresthesia, night cramps and other vein-specific complaints; chronic venous edema, as well as trophic skin disorders, including venous ulcers. Numerous clinical trials indicate that in the early stages of the disease (C0S-C2S) all phlebotropic drugs have a good therapeutic effect on subjective symptoms, but not external manifestations (telangiectasia, varicose reticular and saphenous veins) of CVD.

However, when conducting pharmacotherapy of early stages of chronic venous disease, preference should be given to phlebotropic drugs, whose effectiveness and safety have been proven in randomized controlled clinical trials.
Chronic venous edema (C3) is an absolute indication for the prescription of phlebotropic drugs.
According to the meta-analysis, the most pronounced anti-edematous effect is demonstrated by MOFF (Detralex), which is the first choice drug for chronic venous edema. Hydroxyethylrutosides (Venoruton) and butcher's broom extract (Cyclo 3 fort) also reduce chronic venous edema and can serve as second-line drugs. The effectiveness of non-micronized (native) diosmin against chronic venous edema is not significantly different from placebo. To evaluate the effectiveness of other phlebotropic drugs for chronic venous edema, it is necessary to conduct randomized clinical trials using standardized protocols. Venous trophic ulcers. Currently, the results of only one meta-analysis are known, including 5 randomized controlled trials, according to which MOFF in combination with standard compression therapy accelerates the healing of trophic ulcers with an area of ​​up to 10 cm2 by an average of 5 weeks.

Perioperative period. It is advisable to use phlebotropic drugs to accelerate medical and social rehabilitation and prevent unwanted side effects during phlebosclerosing and surgical treatment of chronic venous disease. Currently, the positive effect of MOFF has been confirmed, significantly reducing the intensity of postoperative pain, swelling and severity of hemorrhages after endovascular and surgical treatment of CVD.

Summary data on the effectiveness of phlebotropic drugs in the treatment of different stages of CVD are presented in Table 7.

Table 7. Efficacy of phlebotropic drugs against various symptoms and syndromes associated with CVD

*currently available evidence base is insufficient

Drugs for the treatment of vein diseases

What does the whole world choose?

Treatment of varicose veins requires an integrated approach and should primarily be aimed at preventing complications of the disease. It is important to understand that it is necessary not only to combine various methods of therapy, but also to strictly follow the doctor’s prescription - this applies to both non-pharmacological treatment (wearing compression stockings, lifestyle changes, gymnastics, etc.) and to taking medications (venotonics ).

An integral part of the fight against varicose veins

- the use of phlebotropic drugs,
venotonics
, which can increase vascular tone and reduce the symptoms of the disease.

Types of venotonics

All drugs used in modern medicine for the treatment of varicose veins are divided into the following categories:

:

· external agents, which are mainly used to relieve symptoms in combination with drugs for oral administration;

· systemic drugs in the form of tablets or suspensions, their action is aimed not only at relieving symptoms, but also at treating the disease.

Drug therapy is considered an integral part of the treatment of varicose veins of the legs.

. With the help of medications, you can increase the tone of the veins, improve microcirculation and lymph flow, and prevent inflammatory complications. They are primarily aimed at the cause of the disease, their target is inflamed vein walls that have lost their tone. Therefore, such drugs form the basis of therapy [1].

Of the wide variety of venoactive drugs, Detralex

[2]. And it is not surprising: the drug has held a strong position in both domestic and international recommendations for many years [1, 3].

Detralex

works comprehensively: increases the tone of the veins, reduces capillary permeability, thereby helping to reduce symptoms such as pain, heaviness, fatigue in the legs, swelling [4].
Thanks to this, Detralex
helps prevent the occurrence of unpleasant complications and the further development of venous diseases [5, 6].

Therefore Detralex

has earned the trust of consumers: it is chosen by millions around the world.[9]

External agents are a variety of gels and ointments

.
Among these drugs is Detragel
, which has a unique composition [7].
It includes heparin, escin and essential phospholipids [8]. The product is quickly absorbed, does not stick and does not stain clothes. Thanks to its composition, Detragel
helps to cope with the symptoms of varicose veins: pain, leg fatigue and a feeling of heaviness [8].

Also, to treat varicose veins, you can apply externally tinctures, lotions and decoctions prepared according to folk recipes. However, such methods do not provide the necessary integrated approach, and their effectiveness has not been proven. In addition, they may not be as safe as they seem at first glance. For example, homemade herbal alcohol tinctures can be irritating to the skin. It is not even the use of folk remedies itself that can pose a serious danger, but rather the refusal to consult a doctor in favor of self-medication. After all, varicose veins do not go away on their own. Its progression can have much more serious consequences. In advanced cases, we are no longer talking about “nets” and “nodules” on the legs, but about thrombosis or trophic ulcers. That is why it is necessary to consult a doctor in a timely manner to prevent such developments.

THERE ARE CONTRAINDICATIONS. YOU MUST CONSULT A SPECIALIST

1. Russian clinical guidelines for the diagnosis and treatment of chronic venous disease. Phlebology, 2021, No. 3, volume 12

2. Surgical monitor: among venoactive (phlebotropic) agents. Spring, 2021.

3. Management of chronic venous disorders of the lower limbs. Guidelines according to scientific evidence. International Angiology 2021. 37(3):181-254. (International guidelines for the treatment of chronic diseases of the lower extremities)

4. Instructions for medical use of the drug Detralex®. RU No. LP-003635.

5. Pascarella L. Essentials of Daflon 500 mg: from early valve protection to long-term benefits in the management of chronic venous disease./Current Pharmaceutical Design. 2007; 13(4):p.431–444 (Pascarella L. Modern Pharmacy 2007; 13(4):pp. 431-444)

6. Sapelkin S.V. et al. Chronic venous diseases: valve function and leukocyte-endothelial interaction, possibilities of pharmacotherapy. Angiology and vascular surgery. Volume 23 No. 3/2017, 89.

7. According to GRLS data among drugs registered in Russia as of March 15, 2018.

8. Instructions for medical use of the drug Detragel®. RU No. LP-001044

9. “Data from the GFK-Rus study on household purchases in the Russian Federation for the period from 07/01/2018 to 06/30/2019.”

As an advertisement.

5.5. Safety of oral phlebotropic drugs

Phlebotropic drugs are well tolerated by the vast majority of patients. Undesirable dyspeptic (abdominal pain, diarrhea, vomiting, etc.) and autonomic (insomnia, dizziness, etc.) are noted by no more than 5% of patients. Undesirable side reactions typical for various phlebotropic drugs are presented in Table 8.

Table 8. Possible undesirable side reactions when using various phlebotropic drugs

* MOFF is safe for long-term (6 months or more) use, and the frequency of unwanted side reactions does not increase

** Synthetic drugs are more likely to cause dyspeptic reactions.

Venotonic preparations for oral administration

Detralex

This is the original preparation of the flavonoids diosmin and hesperidin.

Flavonoids are substances that are part of plants and are involved in photosynthesis, protecting plants from harmful environmental influences. They provide their color and attractive appearance.

They are found in citrus fruits, red sweet peppers, onions, sea buckthorn, blueberries, black currants, plums, hawthorn, rowan, eucalyptus, Japanese sophora and other plants.

In fact, Detralex contains 5 flavonoids, but the main ones are diosmin and hesperidin.

What does “original” drug mean? This means that it was the first to appear on the market with this composition. Manufacturers worked on it for 10-15 years to select the most optimal composition, dosage, release form, maximize its bioavailability, and then carefully researched it for effectiveness and safety.

What effects can you expect from taking Detralex?

For vein disease:

• Pain and swelling are reduced.
• Less commonly, leg cramps.
• Heaviness, fatigue in the legs, and a feeling of fullness are reduced.
• With venous trophic ulcers, healing occurs faster.

For hemorrhoids:

Pain and bleeding are reduced (due to strengthening of the vascular wall).

Composition of Detralex

Detralex 500 (PO tablets):

• Diosmin 450 mg
• 4 other flavonoids, including hesperidin – 50 mg

Detralex 1000 (PO tablets):

• Diosmin 900 mg
• 4 other flavonoids, including hesperidin – 100 mg

1 sachet of suspension has the same composition as Detralex 1000.

Important:

In the production of Detralex, a special micronization technology : under the influence of a stream of air, the particle size of the active substances is reduced to 2 microns. This improves their absorption in the digestive tract and increases the bioavailability of the drug.

Since there are many visitors to the blog who are far from medicine, I will explain:

Bioavailability is the amount of a drug that reaches its site of action in the body. In this case, the venous wall.

Therefore, the higher the bioavailability, the higher the therapeutic effectiveness of the drug.

Contraindications:

• Hypersensitivity to the components of the drug.
• Lactation.

How to take Detralex for vein disease?

Detralex 500:

1 t. in the middle of the day and in the evening with meals. Although I did not find any arguments in favor of taking the drug during the day (and not in the morning) or in the evening. I could still understand this point if Detralex was quickly eliminated from the body. But no. The half-life is 11 hours.

Moreover, I surfed the phlebology forums: doctors recommend taking 2 tablets once in the morning with meals.

But it is better to start with a double dose to check the tolerability of the drug.

In my opinion, it is optimal to offer Detralex 500 to those who have had allergic reactions to medications in the past, so that a person receives a smaller dosage of the substances included in the drug once.

Detralex 1000 and suspension:

1 t. or sachet of suspension 1 time per day (in the morning with meals).

The course for vein disease is at least two months . The drug can be taken without interruption for up to 12 months.

The effect is dose dependent!

Drinking for 2 weeks and quitting because “it doesn’t help” is throwing money away. The first results from treatment with Detralex appear after 2-4 weeks .

The mark on the tablet is not made so that the dosage can be reduced, but solely so that it can be divided to make it easier to take if a person has difficulty swallowing tablets and does not like suspensions.

How to take Detralex for hemorrhoids?

Detralex 500 – 2 t. 3 times a day for 4 days, then 2 t. 2 times a day for 3 days.

Detralex 1000 - 1 t. or sachet in the morning, lunch and evening for 4 days, then 1 t. or sachet in the morning and evening for 3 days.

In case of exacerbation of hemorrhoids, offer Detralex 1000 No. 18 tablets - exactly the amount required for the course.

To consolidate the effect for chronic hemorrhoids, the drug is taken 1 t per day for 1-2 months.

Adverse reactions

• Dizziness, headache, malaise.
• Diarrhea, nausea, vomiting, abdominal pain.
• Itching, urticaria, swelling of the face and lips.

Drug interactions:

Not noted.

Advantages of the drug Detralex

• This is an original drug that has undergone many clinical studies that have proven its effectiveness and safety.
• The particles of active ingredients (unlike most analogues) are microscopic in size. This improves their absorption in the digestive tract and increases their therapeutic effectiveness.
• The drug contains 5 substances (flavonoids) that enhance each other’s effects. Therefore, you can expect that pain, swelling, fatigue, heaviness and cramps in the legs will go away faster than when taking products containing one component.
• New forms of release for oral administration (Detralex 1000 and suspension) allow you to take the drug for vein disease only once a day.
• If you have difficulty swallowing tablets, there is Detralex in the form of a suspension.
• The drug is usually well tolerated. It rarely gives adverse reactions.
• Detralex is compatible with other medications.
• Possible for pregnant women.

Questions for the buyer when selling Detralex

When selling Detralex, ask the buyer questions:

1. Have you been allergic to other medications? (suggest 500 or 1000 mg?)
2. Do you prefer tablets or suspension?

What should the buyer be warned about when selling Detralex?

1. Take the drug with food to avoid side effects (meaning abdominal pain, nausea, vomiting, diarrhea).
2. The first results will be noticeable no earlier than after 2 weeks.
3. The course of treatment must be at least 2 months. More is better: 3-4-6 months for long-lasting results.
4. Pain, swelling, and leg cramps will go away faster if you wear compression stockings. Do you have it? (we make a “bridge” to a complex sale).

Synonymous replacement:

Venarus, Phlebaven

Differences between the drug Venarus and the drug Detralex

1. This is a generic, i.e. There are no sufficient and “correct” clinical studies of its safety and effectiveness. What is “correct”? This means not ordered by the manufacturing company, but honest. This is called a double-blind, randomized, placebo-controlled study.
2. The composition of the active ingredients is the same, but the quantitative composition of the shell excipients is different. This may reduce the therapeutic effectiveness of the drug and produce more side effects.
3. The flavonoids in Venarus are not micronized (not crushed). Consequently, the bioavailability of the drug is lower.
4. No suspension form - Venarus is not suitable for those who have difficulty swallowing tablets.
5. There is no release form for the treatment of acute hemorrhoids, because... the course requires 36 Venarus 500 tablets or 18 Venarus 1000 tablets. The buyer will have to overpay: purchase either 60 tablets. Venarus 500 (or 30+20, which is even more wasteful), or 30 tab. Venarus 1000.

Differences between the drug Phlebaven and the drug Detralex

1. This is a generic. I haven’t found any “honest” clinical studies on it.
2. There is only one dosage - 500 mg, which means taking 2 tons per day.
3. There is no suspension form - the drug is inconvenient to take for those who have difficulty swallowing.
4. The qualitative and quantitative composition of the excipients differs. All this (no doubt) affects the therapeutic effectiveness of the drug and its safety.
5. The manufacturer decided to distinguish itself by coming up with a release form of 32 and 64 tablets. What's the point of this?
6. There is no convenient release form for the treatment of acute hemorrhoids.

Some thoughts:

The manufacturer writes that this is the only generic Detralex in which flavonoids are micronized.

It is not clear how they micronized them there, and what particle size they ended up with.

But for sure: not a single manufacturer of the original drug will reveal the secrets of its production technology.

People are now obsessed with cheap analogues, but they don’t understand one thing: it’s better not to buy sausages, not to go to McDonald’s, to save on beer, cigarettes and other nasty things, but saving on your health can be very expensive.

Judging by the reviews, Fleboven often causes allergic reactions and abdominal pain.

Phlebodia 600

Contains only diosmin.

Surprisingly, in the instructions we read that the drug not only reduces the distensibility of veins, increases their tone, improves microcirculation, but has an anti-inflammatory effect, blocks the production of free radicals, reduces the adhesion of leukocytes to the venous wall and the delivery of oxygen to it.

I wonder why this is not said about Detralex?

The manufacturer also writes that after administration, diosmin accumulates in the venous wall and remains there for up to 96 hours!

The indications are the same.

Contraindications

• Increased sensitivity.
• Persons under 18 years of age.
• Lactation.

Pregnant women - only as prescribed by a doctor. I think the manufacturer is simply playing it safe. But this still means for you that it is not necessary to recommend it during pregnancy.

How to use?

For vein disease:

1 t. in the morning before meals for 2 months.

For acute hemorrhoids:

The first 4 days, 1 t. 3 times a day with meals, 3 days, 1 t. 2 times a day. To do this, choose a package of 18 tablets .

For chronic hemorrhoids, continue taking 1 t. 1 time per day for 1-2 months.

The question arises: why should you take it BEFORE meals for venous disease, and DURING hemorrhoids? As usual, there are no explanations for this. Sometimes you are amazed at the illogicality of what the manufacturer writes. Maybe you have some thoughts on this?

Side effects:

• Heartburn, nausea, abdominal pain.
• Headache.

It turns out that when taking Phlebodia there are fewer side effects. And this is understandable: it contains not five, but one flavonoid. This time. And the daily dosage of diosmin is less. That's two.

Drug interactions:

Not noted.

To summarize:

Differences between the drug Phlebodia and the drug Detralex

1. It contains only one flavonoid, diosmin.
2. The daily dosage of diosmin is less.
3. Diosmin is not micronized, i.e. not crushed, therefore, it begins to act more slowly than Detralex. But the action lasts up to 4 days.
4. Phlebodia not only prevents the expansion of veins, improves blood circulation in the capillaries, but has an anti-inflammatory effect, improves nutrition of the venous wall, and thereby slows down its damage.
5. Gives fewer side effects.
6. No suspension form: inconvenient for those who have difficulty swallowing tablets.

When is the best time to offer a drug based on diosmin alone?

The manufacturer of the drug Detralex assures that the effect is dose-dependent, and the effective dosage of diosmin is 900 mg per day.

Phlebodia contains 600 mg of diosmin. I once took both, and for some reason I liked Phlebodia more: the pain and heaviness in my legs decreased faster.

But if we think logically, a drug based on diosmin alone should be offered in the following cases:

1. When a buyer purchases venotonic for the first time.
2. When there are minor symptoms of vein disease: heaviness in the legs, swelling of the legs in the evening, fatigue. For pain, swelling, cramps, and bulging varicose veins, it is better to suggest Detralex.
3. If a person is allergic to many medications.
4. If the buyer had abdominal pain, diarrhea, rash, or headache while taking Detralex.

Questions for the buyer

Therefore, if a client asks something “for veins” or “heaviness in the legs,” ask:

• What else bothers you: leg muscle cramps at night, swelling, pain? Heaviness in your legs and fatigue only in the evening? Are there any bulging veins on your legs?
• Have you used anything before? What was the effect? Were there any adverse reactions?
• Are you allergic to any medications?

Synonymous replacement for the drug Phlebodia:

Venolek, Vasoket, Phlebofa, Diosmin.

Features of the drug Phlebofa

This is a diosmin preparation without a film coating - so it is logical to assume that there will be fewer side effects, because it usually contains dyes.

Differences between Phlebofa and Phlebodia:

• The quantitative and qualitative composition of the excipients is different. This may affect therapeutic effectiveness.
• There is only one release form - 30 tablets, designed for a month of use.

Everything else is the same as Phlebodia.

Features of the drug Venolek

It contains diosmin not 600 mg, like Phlebodia and Phlebopha, but 500 mg.

Despite the difference in composition, the instructions were almost completely stolen from Detralex.

Same farm. action, same indications, contraindications, side effects.

It is taken similarly to the drug Detralex 500: 1 volume 2 times a day, for acute hemorrhoids - according to the Detralex regimen.

Troxevasin

An old, but very effective drug.

It contains a mixture of derivatives of rutin (vitamin P), a substance that also belongs to flavonoids and improves the condition of blood vessels.

His "tricks":

1. It has an anti-edematous and anti-inflammatory effect (in addition to the fact that it increases the tone of the veins and reduces the fragility of capillaries).
2. Prevents platelet aggregation (sticking together) and reduces the likelihood of blood clots. This is very important for varicose veins, because... complications of varicose veins - thrombophlebitis, deep vein thrombosis.
3. The half-life is 24 hours (versus 11 hours for Detralex).
4. Contraindications: hypersensitivity only.
5. Side effects - nothing criminal: rarely allergic reactions.

How to use?

1 caps. 2 times a day with meals. If you experience leg cramps at night, it is best to take it before bed and in the morning. After improvement, switch to a single dose of 1 capsule. per day for a long time (several months).

Drug interactions

Not noted.

Nothing is said about pregnant and lactating women.

Synonymous replacement:

Troxerutin.

Antistax

His "tricks":

The active ingredient is red grape leaf extract (essentially the same flavonoids).

The therapeutic effect is quite modest:

• Strengthens the walls of blood vessels.
• Reduces their permeability.
• As a result, it slows down the formation of edema and reduces existing edema.

I would recommend it in the initial stages of varicose veins. You shouldn't expect miracles from him.

Contraindications:

• Increased sensitivity.
• Age up to 18 years.

How to use?

2 caps. 1 time a day before meals in the morning. If the effect is insufficient, the dose can be increased to 4 caps. in a day.

Course 12 weeks.

Side effects:

• Rash, itching, urticaria.
• Stomach discomfort, nausea.

Drug interactions

Not checked

5.6. The use of phlebotropic drugs in pregnant women

In the second and third trimesters of pregnancy, MOFF, diosmin, hydroxyethylrutosides and a combination of Ginkgo dicotyledonous extract with heptaminol and troxerutin are allowed. At the same time, the lack of serious clinical studies on the use of phlebotropic drugs in pregnant women makes their use justified only in cases where the benefits of using phleboprotectors outweigh the potential negative reactions. It is not recommended to prescribe phlebotropic drugs during breastfeeding.

Contraindications

Most of these drugs are highly tolerable. Minor side effects (vegetative or dyspeptic) are rare, occurring only in five percent of cases. The main contraindication for the use of a group of drugs is intolerance, allergy to the composition of the drug or a high risk of side effects. Among others, we can highlight:

1. Pregnancy period. Venoruton, DoxyChem and Flebodia are approved for use only in the second and third trimester of pregnancy. Pregnancy is not a contraindication for Venolife. According to the instructions, the use of the drugs Aescusan and Detralex is not prohibited, but the use of the drug is not permitted either. The last word goes to the attending physician. And the drug Ginko Forte, according to the instructions for use, is strictly prohibited for pregnant women.
2. Breast-feeding. While there is no reliable data on the effect of active substances on mother's breast milk, the use of phlebotropic drugs in nursing mothers is prohibited.
3. Age. Venotonics Ginko Forte, Cyclo 3Forte (18), Phlebodia, Doxichem contain age restrictions in their instructions. Troxevasin and troxerutin have different age restrictions. For example, the instructions for using troxevasin are silent about such restrictions. And the instructions for troxerutin say that there are not enough experimental clinical trials for use under 18 years of age. Other phlebotropic medications do not contain age restrictions on the use of the drug.

5.8. Regimen for taking and dosing phlebotropic drugs

Adequate doses of phlebotropic drugs recommended by manufacturers should be prescribed, and standard treatment regimens and durations should be followed. Exceeding standard daily doses does not always increase the clinical effect, but increases the frequency of unwanted side reactions that disrupt the initiated course of pharmacotherapy. However, a number of studies indicate that in certain clinical situations, increasing the dose of a phlebotropic drug can increase its therapeutic effectiveness. In this regard, in situations where the benefit outweighs the potential risk, the dose of the phlebotropic drug may be increased after documented justification and obtaining informed consent from the patient.

It is advisable to prescribe phlebotropic drugs in the form of monotherapy or fixed combinations*, since the simultaneous use of two or more drugs belonging to related chemical classes does not enhance the therapeutic effect, but increases the likelihood of developing undesirable side reactions.

* fixed combination is a multicomponent drug

Phlebotropic drugs are prescribed in courses, the duration of which is selected empirically, based on the dynamics of symptoms and syndromes, the duration of remission, and the occurrence of undesirable side reactions. For patients with the initial stages of chronic venous disease (C0S-C2S), the duration of the standard course ranges from 1.5 to 3 months (2.5-3 months on average). For chronic venous edema (C3), trophic skin disorders, and especially open ulcers (C4-6), phlebotropic drugs can be prescribed for 6 months or more.

It is advisable to start a course of phlebotropic drugs with the period of expected exacerbation of the disease or a possible violation of the compression regime. Thus, the use of compression therapy is difficult in the hot season, when working in conditions of high temperature and humidity, as well as when it is necessary to comply with a dress code. A negative background, often leading to an exacerbation of the course of chronic venous disease, is created by a long forced stay in a sitting or standing position (many hours of air flights, travel by bus or car, etc.), an increase in work (heavy lifting, etc.) or household (housework or on a personal plot, caring for bedridden patients, etc.) physical activity.

In severe forms of CVI, especially in obese patients who experience insurmountable difficulties wearing compression bandages or medical hosiery, as well as when compression therapy is not possible, phlebotropic drugs are prescribed for continuous use. MOFF has the highest safety profile for long-term (6-12 months) use.

5.9. Local dosage forms for the treatment of chronic venous disease

The therapeutic effect of local medications is largely due to the distracting effect due to the evaporation of volatile components (local hypothermia) and massage during application and rubbing of the drug. The seemingly rapid therapeutic effect of local drugs quickly wears off and requires their repeated use. It must be clearly understood that local dosage forms should be used in combination with compression therapy and systemic drugs.

Local dosage forms in the form of gels and sprays, including heparin, NSAIDs and phleboprotectors, are advisable to use for rapid relief of vein-specific symptoms (pain, feeling of heaviness and heat, local swelling, etc.). Their use is not recommended for asymptomatic forms of CVD.

The effectiveness of various ointments and gels is directly dependent on the concentration of the active substance. In this regard, when prescribing heparin-containing gels, preference should be given to drugs with a high concentration of the active substance of 500-1000 IU/gram.

Contraindications to the use of local dosage forms (with the exception of corticosteroids and dermatoprotectors) are damage to the skin (erosion, excoriation), dermatitis and eczema, as well as open trophic ulcers.

Properties of drugs

Venotonics are divided depending on their composition into herbal, synthetic and semi-synthetic. The composition of herbal phlebotropic preparations includes biological additives and active compounds (saponins, flavonoids). Almost all phlebotropic medications have shown high effectiveness in treating subjective symptoms at the earliest stages of their course. Detralex has pronounced anti-edematous properties and best fights chronic venous edema. Drugs such as Cyclo 3 Fort and Venoruton also work well as a treatment for such a disease; they can be used as second-line drugs.

According to multiple clinical studies, Detralex in combination with compression therapy significantly increases the healing rate of small venous ulcers. In addition to all of the above, phlebotropic drugs increase the level of rehabilitation after treatment of venous disease through surgery and reduce the likelihood of side effects after surgery.

5.10. Antiplatelet and other drugs used in the treatment of CVD

Antiplatelet and hemorheologically active drugs (acetylsalicylic acid drugs 50-150 mg/day, pentoxifylline 1200-2400 mg/day) are advisable to prescribe in the presence of appropriate concomitant pathology (diabetes mellitus, obliterating atherosclerosis, etc.).

For chronic venous edema and trophic skin disorders (C3,4,5 according to CEAP), the use of polyenzyme drugs (wobenzym, phlogenzyme) in standard therapeutic dosages may be useful. Due to the fact that polyenzyme drugs in some cases can contribute to the destruction of biological membranes and exacerbation of the local infectious process, it is advisable to combine them with rational antibacterial therapy.

A comment

. For venous trophic ulcers, sulodexide can be used as an additional therapy. The role of multienzyme drugs in the treatment of chronic venous disease requires further study. The use of prostaglandins for the treatment of chronic venous disease is possible in the presence of trophic skin disorders and ulcers of mixed arteriovenous origin.

5.11. Monitoring the effectiveness of treatment

One should strive to objectify the assessment of the effectiveness of the treatment. For complaints and subjective symptoms, it is useful to use visual analogue scales and disease-specific questionnaires (CIVIQ, etc.). When monitoring the dynamics of chronic venous edema, it is advisable to use a measuring tape or more precise instruments (leg-O-meter, volumetric meter, etc.).

In case of trophic skin disorders, the effectiveness of the treatment is indicated by a decrease in inflammatory phenomena and the area of ​​indurative cellulite, as well as signs of epithelization of a venous ulcer.

If there is no effect from the therapy, it is necessary to carry out additional differential diagnostics.