What is the evaluation & treatment strategy for Raynaud's

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What is the evaluation and treatment strategy for Raynaud's

phenomenon? by Tagliarino, M.D

Journal of Family Practice

* Evidence summary

Raynaud's phenomenon is diagnosed by a history of cold temperatures

or emotional stress precipitating episodic digital artery vasospasm,

according to expert opinion. This presents as well-demarcated

digital pallor and cyanosis, often followed by reactive hyperemia

occurring 15 to 20 minutes after rewarming. (1,2) No reliable office

test confirms the diagnosis. By definition, primary Raynaud's

phenomenon occurs in the absence of associated diseases and is

considered an exaggerated vasoconstrictive response to cold. It must

be distinguished from normal mottling of the digits in response to

cold temperatures, effects of vasoconstrictive medications,

environmental injury (frostbite, use of vibrating tools),

neuropathy, and thoracic outlet syndrome. (1,2) Experts differ on

whether laboratory evaluation with erythrocyte sedimentation rate

and an antinuclear antibody test is necessary for patients with

primary Raynaud's phenomenon. (1,3)

Patients with secondary Raynaud's phenomenon have an underlying

cause or disease, such as scleroderma or systemic lupus

erythematosis. (2) The finding of distorted capillaries in the nail

folds using an ophthalmoscope set at 40+ diopter magnification is

the best predictor of an associated connective-tissue disease. (4) A

cold-water challenge to trigger an attack of Raynaud's phenomenon

produces inconsistent results and is not recommended. Research tools

such as thermographic and laser Doppler imaging can measure digital

artery blood flow but are rarely used clinically. (1,5) Patients

with secondary Raynaud's phenomenon should have a complete blood

count, biochemistry profile, and urinalysis. They may need

additional tests as determined by the nature of their underlying

disease. (1)

Conservative management is helpful for all patients with Raynaud's

phenomenon, and may be the only treatment needed. Experts advise

dressing warmly, wearing gloves when appropriate, using abortive

strategies such as placing the hands into warm water, and avoiding

sudden cold exposure, emotional stress, and vasoconstrictive agents

such as nicotine. (6)

Medication may be helpful for patients whose symptoms are not

controlled with conservative measures. Six randomized, placebo-

controlled trials involving 451 people with primary Raynaud's

phenomenon demonstrated that nifedipine decreases the mean frequency

of vasospastic attacks. Three of these trials also showed subjective

improvement in symptom severity with nifedipine vs placebo. A meta-

analysis of 6 randomized crossover studies compared nifedipine or

nicardipine with placebo in 59 patients with secondary Raynaud's

phenomenon and underlying systemic sclerosis. Nifedipine

significantly decreased the frequency and severity of attacks.

Nicardipine showed a trend towards reduced symptoms in 1 trial with

only 15 patients. (8) Another randomized trial comparing sustained-

release nifedipine to placebo showed a 66% reduction in the number

of attacks in the treatment group at 1 year; 19 of the 77 people in

the nifedipine group dropped out of the study, as did 24 of the 81

people in the placebo group. (9)

A systematic review of 2 randomized controlled trials with a total

of 40 patients found prazosin modestly effective in secondary

Raynaud's phenomenon, but it was less well-tolerated than calcium

channel blockers. (10) Single, small randomized crossover trials

showed improved responses to both fluoxetine (11) and losartan (12)

when compared with nifedipine. In general, these medications appear

to reduce attacks by 30% to 40%.

Small, prospective studies of low-level laser irradiation, palmar

sympathectomy, and endoscopic thoracic sympathectomy show some

benefit for patients with digital ulcers. (13-15) A randomized

controlled trial showed biofeedback was ineffective for voluntary

control of digital blood flow for patients with Raynaud's

phenomenon. (9)

Recommendations from others

The American College of Rheumatology does not offer recommendations

for the diagnosis or treatment of Raynaud's phenomenon. UpToDate

recommends treatment with conservative measures; sustained-release

nifedipine or amlodipine may be used if these are insufficient.

Other vasodilators may be added or substituted in the event of an

adverse reaction or poor response to the calcium-channel blocker.

(16)

EVIDENCE-BASED ANSWER

Raynaud's phenomenon is diagnosed by history, which also plays a key

role in distinguishing primary from secondary Raynaud's phenomenon

(strength of recommendation [sOR]: C, based on expert opinion). The

initial treatment includes conservative measures such as the use of

gloves, cold avoidance, and rapid rewarming (SOR: C, based on expert

opinion); in refractory cases, the vasodilatory agents nifedipine or

prazosin alleviate symptoms (SOR: A for both, based on multiple

randomized controlled trials) (TABLE).

CLINICAL COMMENTARY

Reserve pharmacotherapy for cases that are resistant to conservative

measures

Raynaud's phenomenon is one of those clinical syndromes that stirs

the desire to find an exotic explanation, such as systemic lupus

erythematosus, but most often yields less glamorous results. Usually

I must tell patients that I can't explain the cause and recommend

that they keep their hands as warm as possible to avoid the

symptoms. I have learned to discipline myself over the years to

pursue a connective tissue cause only when other signs or symptoms

of such a disease are also present. The use of the ophthalmoscope at

high power to look for distorted nail-fold capillary loops is a

helpful pearl.

I reserve pharmacotherapy for cases that are resistant to

conservative measures due to the cost and side effects of the drug

options.

Grant Hoekzema, MD

Mercy Family Medicine Residency, St. Louis, Mo

TABLE

Primary therapies for Raynaud's phenomenon

RECOMMENDATION

TREATMENT LEVEL COMMON ADVERSE EFFECTS

Nifedipine A Lower extremity edema,

flushing, headache, dizziness

Prazosin A Dizziness, hypotension, palpitations

Conservative C --

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Available at: www.uptodate.com. Accessed on May 9,