Expert Opinion on Pharmacological Treatment of Diabetic Peripheral Arterial Disease: Clinical Utility of Cilostazol/Ginkgo biloba Extract Combination (Renexin®)

Peripheral arterial disease (PAD) is a macrovascular complication of diabetes mellitus associated with a high risk of cardiovascular events, lower-extremity amputation, and impaired quality of life. Cilostazol, a phosphodiesterase-3 (PDE3) inhibitor, is recommended as a first-line pharmacological agent for symptomatic PAD based on evidence that it helps improve walking distance and potentially stabilizes plaques, partly mediated by favorable effects on triglycerides and high-density lipoprotein cholesterol. Ginkgo biloba extract improves hemorheological parameters, including plasma viscosity and hematocrit, and may increase ankle-brachial index in patients with type 2 diabetes mellitus. Also, when used in combination therapy, cilostazol attenuates carotid intima-media thickness progression. However, high-quality evidence for G. biloba extract in diabetic PAD remains limited. Based on a comprehensive review of available clinical evidence and expert consensus, this expert opinion recommends G. biloba extract combination with cilostazol (Renexin®) as a second-line agent or adjunctive therapy primarily for symptom control—particularly the improvement of maximal walking distance—in patients with diabetic PAD who experience insufficient symptom control or intolerance to cilostazol monotherapy. This expert opinion also emphasizes individualized patient selection, careful screening for contraindications, and regular clinical monitoring, and urges large-scale randomized controlled trials in Korean patients with PAD to further establish a greater evidence base for pharmacological treatment.