Medical Management of Raynauds Phenomenon

Medical Management of Raynauds Phenomenon

Which medications have been useful in the management of Raynauds Phenomenon?

All available therapies work better in primary RP than in secondary RP. However, medications beyond CCB are not commonly required for primary RP.

Pearl: RP resistant to CCB therapy should prompt consideration of a workup for secondary disease.

Medications in the Management of RP
MedicationAppropriate target population, dosing information, side effects
CCBsNifedipine, amlodipine, felodipine, diltiazem. Slow-release preparations most commonly used.
Best studied vasodilator therapy; improve symptoms in one-third of primary RP
Verapamil & nicardipine are not effective
Nifedipine also inhibits platelet activation
Side effects: edema, constipation, lightheadedness, headache, worsening GERD
Avoid in pregnancy; use dihydropyridine class in patients with ventricular dysfunction or PH
Sympatholytic agents (e.g. prazosin)Typically short-term use (loses effectiveness over time)
Side effects: postural hypotension
Topical nitrates (2% nitroglycerin)¼ to ½ inch ointment applied two to three times daily
A rest from nitrates for 12 hours necessary to prevent development of a refractory state
Best reserved for patients with recalcitrant disease of only a few digits
Consider alternative if heart failure and/or PH present
Side effects: headache
Avoid touching eyes post application as well as concurrent use of PDE5 inhibitor (sildenafil)
PDE5 inhibitorsSildenafil 20 mg two to three times daily
Endothelin-1 antagonistsBosentan
Reduced new ulcer formation in clinical trials
Side effects: LFT abnormalities (monitor Q4weeks), headache, flushing, edema
Prostacyclin analoguesEpoprostenol, iloprost, treprostinil
Vasodilators and platelet aggregation inhibitors
Commonly administered intravenously (oral formulations exist, but studies on effectiveness in this setting are conflicting)
Studied in refractory disease; best reserved for patients with severe digit threatening disease
Drug availability may be limited. High cost.
Side effects: flushing, jaw pain, headache, diarrhea, nausea
StatinsAtorvastatin shown to decrease frequency of RP and reduce ulcer formation
Mechanism of action: potential vascular effects through inhibition of the rho-kinase pathway that regulates alpha 2c adrenoreceptor expression
SSRIsFluoxetine shown to decrease severity and frequency of Raynaud’s attacks
ARBsLosartan shown to decrease severity and frequency of Raynaud’s attacks
Platelet-directed therapyASA (75–81 mg daily): limited data, but commonly recommended in secondary RP with a history of digital infarcts or other signs of vascular insufficiency
Dipyridamole, clopidogrel, pentoxyphylline: limited efficacy data
AnticoagulationConsider if evidence of embolization or new thrombosis
Consider short-term use (heparin) in periods of critical ischemia (Question 19)
Consider long-term use (Coumadin) in resistant disease if antiphospholipid antibodies present
Thrombolytic therapyNo formal recommendation; needs additional study

ARBs, Angiotensin receptor blocker; GERD, gastroesophageal reflux disease; LFT, liver function test; PDE5, phosphodiesterase type 5 inhibitor; PH, pulmonary hypertension; SSRIs, selective serotonin reuptake inhibitors.

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