Raynaud's Phenomenon
NHS Tayside RefGuide
Referring to secondary care
Refer to rheumatology if Raynaud’s with any features of a connective tissue disease or patients are not responding to treatments. If there are ulcers or tissue loss then please refer urgently.
Background
Raynaud’s phenomenon can be defined as exaggerated vasospam in response to cold weather, causing the typical triphasic white, blue and red colour changes.
- Can occur on its own (primary Raynaud’s), especially in young women/ teenagers. It is often bilateral and there may be a family history. Most people do not go on to develop further problems.
- It can be an initial symptom of an autoimmune disease (secondary Raynaud`s) such as systemic sclerosis, SLE and myositis, especially when it occurs after the age of 25.
Investigations
FBC, U&Es, PV, CRP, TSH and CTD screen.
Diagnosing Raynaud’s phenomenon
Symptoms of discomfort in fingers/toes associated with:
- Triphasic colour change:
- White (pallor)
- Blue (cyanosis)
- Purple (hyperaemia)
- Triggers:
- Cold exposure
- Smoking
- Stress
- Vibration tools
- Medications(Beta-blockers)
- Any features of CTD?
- Puffy hands, skin tightening
- Digital ulcers or pitting
- Arthralgia/arthritis
- Rash, photosensitivity
- Sicca symptoms
- Unilateral symptoms
- Muscle weakness
- Late onset symptoms.
Management
Conservative management
- Lifestyle advice, limit exposure to triggers. Warm clothing centrally and peripherally, heat pads etc.
- Smoking and electronic nicotine device cessation.
Drug therapy
First line for primary or secondary Raynaud's:
Calcium channel blockers (Ia) and angiotensin II receptor antagonists (Ib,C).
- Nifedipine (retard formulation) 10mg nocte for 2 weeks, then 10mg mane for 2 weeks, then 10mg bd. Dose can be increased up to a maximum of 30 mg BD.
- Amlodipine 5mg
- Felodipine MR 2.5 – 5mg
- Lercanidipine 10mg
- Diltiazem 60mg bd
- Losartan 25 -50mg.
Second line treatments for patients with secondary Raynaud`s with or without digital ulceration:
Sildenafil (Ia) should now be used before considering Iloprost, Bosentan, Botox injection or Digital sympathectomy.
Starting dose for Sildenafil is 25mg twice daily (can up titrate to a maximum 50mg three times daily) (See TAF for latest prescribing info).
Other treatments
Selective serotonin reuptake inhibitors, α-blockers and statin therapy. (IIIc).
Stopping drug therapy
Many patients will have marked seasonal variation to their symptoms and are therefore able to stop their vasodilator therapy in the warmer months. Assessing positive response to therapy can be difficult as is based on subjective symptom reporting. If no perceived benefit, it is advised that the drug is stopped and an alternative option considered.