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 | |
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Medication | Appropriate target population, dosing information, side effects |
CCBs | Nifedipine, 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 inhibitors | Sildenafil 20 mg two to three times daily |
Endothelin-1 antagonists | Bosentan Reduced new ulcer formation in clinical trials Side effects: LFT abnormalities (monitor Q4weeks), headache, flushing, edema |
Prostacyclin analogues | Epoprostenol, 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 |
Statins | Atorvastatin 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 |
SSRIs | Fluoxetine shown to decrease severity and frequency of Raynaud’s attacks |
ARBs | Losartan shown to decrease severity and frequency of Raynaud’s attacks |
Platelet-directed therapy | ASA (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 |
Anticoagulation | Consider 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 therapy | No 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.