Which sclerosants are used in the treatment of varicose veins and spider veins (telangiectasia)?

Updated: Feb 28, 2018
  • Author: Robert Weiss, MD; Chief Editor: William D James, MD  more...
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Answer

The most commonly used sclerosants today are polidocanol and sodium tetradecyl sulfate, both known as detergent sclerosants because they are amphiphilic substances that are inactive in dilute solution but are biologically active when they form micelles. These agents are preferred because they have a low incidence of allergic reactions, produce a low incidence of staining and other cutaneous adverse effects, and are relatively forgiving if extravasated. [12] These are best delivered as a foam, which is made by agitating the solutions with air to create a frothy substance.

Sodium morrhuate is an older detergent sclerosant that is made up of a mixture of saturated and unsaturated fatty acids extracted from cod liver oil. The agent is of variable composition and has been associated with a relatively high incidence of anaphylaxis. The incidence of extravasation necrosis is high with this drug.

Ethanolamine oleate, a synthetic preparation of oleic acid and ethanolamine, has weak detergent properties because its attenuated hydrophobic chain lengths make it excessively soluble and decrease its ability to denature cell surface proteins. High concentrations of the drug are necessary for effective sclerosis. Allergic reactions are uncommon, but reports exist of pneumonitis, pleural effusions, and other pulmonary symptoms following the injection of ethanolamine oleate into esophageal varices. The principal disadvantages of the drug are a high viscosity that makes injection difficult, a tendency to cause red cell hemolysis and hemoglobinuria, the occasional production of renal failure at high doses, the possibility of pulmonary complications, and a relative lack of strength compared with other available sclerosants.

Hypertonic sodium chloride solution in a 20% or 23.4% solution can be used as a sclerosing agent. The principal advantage of the agent is the fact that it is a naturally occurring bodily substance with no molecular toxicity, but the disadvantages of the agent make it unsuitable except in the hands of highly skilled practitioners. Because of dilutional effects, achieving adequate sclerosis of large vessels without exceeding a tolerable salt load is difficult. It can cause significant pain on injection and significant cramping after a treatment session. If extravasated, it almost invariably causes significant necrosis. Seeing patients with dozens of disfiguring scars at the sites of extravasation of hypertonic sodium chloride solution is not uncommon. Because it causes immediate red blood cell hemolysis and rapidly disrupts vascular endothelial continuity, it may cause marked hemosiderin staining that is not cosmetically acceptable.

Food and Drug Administration (FDA) approval of drug labeling is an important concern for physicians and patients in the United States. Polidocanol is approved by the FDA. Sotradecol, sodium morrhuate, and ethanolamine oleate all were developed prior to the establishment of the FDA. These agents are available in the United States as grandfathered agents. The newest form of Sotradecol was cleared by the FDA in 2006. It is highly purified with no contaminants.

In November 2013, the FDA approved polidocanol injectable foam (Varithena), a pharmaceutical-grade, low-nitrogen polidocanol foam dispensed from a proprietary canister device, for the treatment of incompetent veins and visible varicosities of the great saphenous vein system. Approval was based on 2 placebo-controlled studies, in which most of the treated patients experienced clinically meaningful improvement of the symptoms of superficial venous incompetence and the appearance of visible varicosities. [13]

According the National Institute for Health and Care Excellence (NICE) guidelines, foam sclerotherapy is considered second-therapy after endovenous ablation. [14]

The safety of sclerosing agents in pregnancy has not been established.


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