Drug Therapy

Raynaud’s phenomenon (RP) may warrant pharmacological treatment if there are significant symptoms not controlled by nonpharmacological treatment or complications. 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 (avoiding cold, stress and other precipitators, and stopping smoking). In general, secondary RP is more severe than primary. The majority of patients with both primary and secondary RP do not require drug treatment. However, patients with the most severe RP, for example, patients with systemic sclerosis (SSc), usually require drug treatment. 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 30% 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, phosphodiesterase type 5 (PDE5) inhibitors are considered and/or prostacyclins such as intravenous iloprost. In mild RP, PDE5 inhibitors, losartan (an angiotensin II receptor blocker) or fluoxetine (a selective serotonin reuptake inhibitor) may be considered with some positive randomized controlled trial data to support their use. 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 and are not recommended. Most experts suggest treatment of uncomplicated moderate to severe RP using combinations of drugs. For example, adding a PDE5 inhibitor after obtaining a partial response with a CCB. When using combination treatment, the chances of hypotension are increased, so blood pressure must be monitored.