Raynaud’s Phenomenon: A Guide to Pathogenesis and Treatment

Abstract

Sometimes Raynaud’s Phenomenon (RP) is symptomatic enough to warrant pharmacological treatment. The principles of RP treatment are to decrease the frequency of attacks, lessen the duration of attacks, and to prevent or treat complications especially after failure of conservative treatment (staying warm, avoiding stress and other precipitators, and smoking cessation). In general secondary RP is more severe than primary and the majority of patients with both primary and secondary RP do not require drug treatment. However, the most severe RP patients are often those with arterial occlusion/obliteration such as those with systemic sclerosis associated RP. First line drug treatment is initiation of dihydropyridine class of calcium channel blockers (CCBs), where the most studied is nifedipine. Achievable goals of treatment with CCBs may be a 1/3 reduction in frequency of attacks. Other CCBs could be considered such as amlodipine, felodipine, and nicardipine. If this class is not effective or not tolerated (due to side effects such as hypotension and peripheral edema), then in moderate to severe secondary RP, PDE5 inhibitors are considered and or prostacyclins such as intravenous iloprost. In mild RP, PDE5 inhibitors or losarten (an angiotension II inhibitor) or fluoxetine (a selective serotonin reuptake inhibitor) may be considered with some positive randomized controlled trial data. Topical nitrates may be helpful, but there can be dose dependent side effects such as headache and hypotension. Angiotensin-converting-enzyme inhibitors have mostly negative data. Trends in treatment of uncomplicated moderate to severe RP are using combinations of drugs if tolerated and after obtaining a partial response with CCBs such as adding PDE5 inhibitors. Complications of secondary RP (both prevention and treatment) are discussed in Chap. 19.