MUDr. Petr Majtan: Venofarmaka should receive at least partial coverage for hemorrhoidal disease − their benefit in this indication is clear

Model candidate for venopharmacotherapy

How has the approach to venopharmaka in practice changed over the time you have been treating CVD?

Venopharmaka have been used in the treatment of CVD for a long time, gradually different medications with varied compositions have appeared. Recently, drugs containing flavonoid fractions, predominantly diosmin in micronized and purified form, have taken the lead.

Based on your experience, how would you describe the model candidate for venopharmaka administration? 

Typically, it is a patient with manifestations of chronic venous insufficiency of the lower limbs – these can be functional or morphological. They suffer from feelings of heaviness, pressure, and tension, night cramps, swelling, spider veins, larger varicose veins, and in the final stage, trophic changes including venous ulcers. I also use venopharmaka to treat hemorrhoidal disease besides CVD.

How to use venopharmaka in the early stages of venous impairment?

It is standardly recommended to dose 1x daily, taking a tablet with 2500 mg of the active ingredient; alternatively, 1 tablet can be taken in the morning and evening. Patients should feel an improvement after about 4 weeks of therapy. If this happens, long-term treatment is possible, most commonly with 1 tablet per day. A surgical procedure is an alternative in CVD therapy, which some patients with an early-stage disease do not yet want to undergo and are satisfied with the conservative modality.

A modality suitable before, after surgery, and in the interim between operations

Is it possible to recommend venopharmaka as an adjunct therapy to surgical methods indicated in more advanced stages of CVD? 

Absolutely, it can be used concurrently with practically all types of surgical CVD treatments – both minimally invasive procedures (such as sclerotherapy, CHIVA or laser methods), and conventional procedures (radical varicose vein surgery under anesthesia).

Can venopharmaka be indicated in patients with repeated venous surgeries? If so, when should the treatment start and how best to continue?

Venopharmaka can be indicated in repeated surgeries and are used when surgery does not completely relieve a patient’s subjective problems (night cramps, feelings of heaviness, pressure, or pain), or in the transitional period if another surgical therapy is planned (for example, after a radical surgery of stem varices, sclerotherapy of small varicosities often follows in the second stage, and if the patient has problems in the interim, he can use venopharmaka).

What benefits do you observe in everyday clinical practice?

Venopharmaka have the greatest response among patients where CVD has not yet reached advanced stages and they still have relatively significant subjective difficulties. In this case, venopharmaka (temporarily even at a higher dose) usually provide relief.

Against CVD complications, effects on three levels

How can venopharmaka act in the prevention of CVD complications?

By acting on several levels: At the level of macrocirculation, it improves venous elasticity and reduces venous stasis. At the microcirculation level, it improves capillary permeability and capillary resistance. And at the lymphatic level, it increases lymphatic flow. These mechanisms adjust the function of the venous and lymphatic systems towards a normal state and function, thus reducing the risk of complications, the most serious of which is probably the development of a venous ulcer.

At what age do your patients start using venopharmaka? Do you think it is timely enough, or should they start this treatment earlier?

Generally, patients visit their doctors in the vast majority of cases after several years, or even decades, of CVD because the disease is asymptomatic for a long time. They seek a doctor due to the development of some accompanying unpleasant subjective symptoms. For instance, quite a number of women are brought to the specialist’s office by the aesthetic aspect of the issue.

What is the gender distribution in terms of CVD prevalence? And how does age factor into this statistic?

Among my patients, women clearly predominate. This is due to the effect of female sex hormones on the venous wall, pregnancy, and childbirth, during which the disease often manifests for the first time. It progresses further with age. If the difficulties reach a certain level that bothers the patient, they decide to visit a doctor. For women, the aesthetic aspect also plays a far greater role.

Safe treatment with minimal side effects in practice

What impact does it have that venopharmaka containing diosmin are available in micronized form?

That is a question more suitable for a pharmacologist, but generally, it is stated that the micronized fraction of flavonoids is more effective due to its larger surface area (achieved through micronization), thereby leading to better absorption and bioavailability of the active substance in the body.

If patients decide to use over-the-counter venopharmaka, what should they consult with their doctor besides the dosage?

Fortunately, venopharmaka belong to relatively safe medications with few side effects – most often dyspepsia, a feeling of nausea, or diarrhea, but these problems are not reported too frequently. As with almost all medications, the use of venopharmaka is not recommended during pregnancy and breastfeeding.

Is the potential of venopharmaka fully utilized in practice at present, or do you still see some gaps in this regard?

In the case of CVD, I would say the situation has greatly improved in recent years, which surely correlates with the expansion of the portfolio of over-the-counter venopharmaka. I see gaps in the case of hemorrhoidal disease, where despite the clear benefits, there is still no partial coverage from public health insurance in this indication.

Kristýna Poulová
editor proLékaře.cz