Raynaud’s Phenomenon

Posted by • August 11th, 2016

raynaud cover picAlthough laboratory testing provides important information about the hemodynamic and physiological features of Raynaud’s phenomenon, clinical assessment by means of history or direct observation remains the best approach for diagnosis. Most experts agree that at least biphasic (white [pallor] and blue [cyanosis]) change in the skin color of the digits is needed. A new Review Article updates the understanding of the pathogenesis, the approach to management, and current approaches to drug therapy.

Clinical Pearl

What type of disease is most often associated with secondary Raynaud’s phenomenon?

Patients who initially present with Raynaud’s phenomenon and then have progression to an underlying secondary disease generally have a connective-tissue disease, commonly systemic sclerosis (scleroderma). One study showed that 37.2% of 3029 persons who were thought to have primary Raynaud’s phenomenon subsequently had a connective-tissue disease.

Clinical Pearl

Are there factors which help to predict whether a patient with isolated Raynaud’s phenomenon will go on to manifest a secondary underlying disease?

Recent studies have emphasized that factors such as the onset of Raynaud’s phenomenon near the age of 40 years, severe frequent events, and the presence of abnormal nailfold capillaries can help predict whether a connective-tissue disease will develop and are especially helpful in identifying early scleroderma. A survey that followed 299 patients with primary Raynaud’s phenomenon for a median of 4 years showed that if capillaroscopy reveals normal nailfold capillaries and if all tests for scleroderma-specific antibodies are negative, then the chance that scleroderma will develop is less than 2%.

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Morning Report Questions

Q: What nonpharmacologic therapies are recommended for Raynaud’s phenomenon?

A: Although evidence from clinical trials is still needed to provide solid guidelines, there is little doubt that effective cold avoidance and stress reduction constitute the foundation of any treatment program for Raynaud’s phenomenon. This approach alone treats the majority of patients who present with primary Raynaud’s phenomenon and is also a major factor in treating patients with secondary Raynaud’s phenomenon. Systemic warming is best accomplished by keeping the whole body warm with layered clothing, gloves, and head covering; avoiding rapidly shifting temperatures, such as rushing into an air-conditioned area; and avoiding cold and breezy conditions. Local hand warming with gloves and rubbing the hands in warm water or with chemical warmers can help prevent an attack or speed recovery. A variety of factors can potentially aggravate the disorder and should be avoided, including smoking and the use of sympathomimetic drugs, agents for the treatment of attention deficit–hyperactivity disorder, and agents for the treatment of migraine headaches.

Q: If nonpharmacologic approaches do not control Raynaud’s phenomenon, are there effective pharmacologic therapies? 

A: Drug therapy is initiated when nonpharmacologic approaches are ineffective in reducing the severity of vasospastic attacks and improving quality of life. Currently, a popular clinical practice is to use a long-acting dihydropyridine calcium-channel blocker as monotherapy, adjusted to the maximally effective dose with the fewest side effects. A 2005 meta-analysis of randomized trials involving 361 patients with primary Raynaud’s phenomenon showed benefit with the use of calcium-channel blockers, with a reduction in the frequency of attacks by an average of 2.8 to 5 attacks per week. A recent Cochrane review provided moderate-quality evidence that oral calcium-channel blockers are minimally effective in the treatment of primary Raynaud’s phenomenon as measured by the frequency of attacks; there were 1.72 fewer attacks per week (95% confidence interval [CI], 0.60 to 2.84) with a calcium-channel blocker than with placebo. A 2001 meta-analysis of randomized trials involving patients with scleroderma and Raynaud’s phenomenon supported the view that these drugs are moderately effective in patients with secondary Raynaud’s phenomenon. If calcium-channel blockers are ineffective as determined by self-reported responses by patients on an office-administered Raynaud’s Condition Score, if they cannot be taken because of side effects, or if there is persistence of a secondary complication with digital ischemic lesions, popular options include the use of a phosphodiesterase type 5 (PDE-5) inhibitor or a topical nitrate, alone or in combination with the calcium-channel blocker. There is also some evidence to support the use of selective serotonin reuptake inhibitors (SSRIs) or angiotensin II–receptor blockers (ARBs).

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One Response to “Raynaud’s Phenomenon”

  1. Scott speer says:

    L-Argine works for me on this.