44 - Raynaud Phenomenon

Question 1

Characterized by what?

Answer 1

White to blue to red

Blanching of fingers (normally when exposed to cold), followed by a second cyanotic phase then by a reactive hyperhemia phase

Question 2

What drugs can cause RP ?

Answer 2

• Antineoplastics (bleomycin, vinblastin, and cisplatin)
• BBs (unlikley but controversial)
• CNS stimulants (dexamphetamine, methylphenidate)
• Cyclosporine - not dose related
• Ergot derivatives
• Interferon alfa or beta

Question 3

Non-pharms

Answer 3

minimize cold exposure, avoid meds with VASOCONSTRICTIVE potential, teach warming exercises, dress warmly in winter, stop smoking

*meds for treatment of RP are focused on vasodilation

Question 4

What type of calcium channel blockers are first line?

Answer 4

DHP (ex. nifedipine)

*Nifedipine is best studied

Question 5

How should they use nifedipine?

Answer 5

30-60 mins before cold exposure or regularly during winter months

Question 6

Can you use non-DHP CCB’s for RP?

Answer 6

you can but they are less effective than DHPs

Question 7

What is another option?

Answer 7

peripheral alpha blockers (ex. prazosin)

• less effective than CCBs

Question 8

What type of ointment can you try?

Answer 8

nitroglycerin 2% ointment but may be difficult to use due to s/e of headache and hypotension

Question 9

What IV drug may be good for short-term use for severe secondary RP ?

Answer 9

IV iloprost (PG analogue)

• the oral form is less effective
• not available in Canada

Question 10

Can also use Ketanserin (5HT antagonist) to reduce duration of symptoms. Problem with this ?

Answer 10

not available in Canada

Question 11

________ heals digital ulcers and decreases RP in patients with systemic sclerosis

Answer 11

Bosentan (endothelin-1-inhibitor)

Question 12

What drugs used for ED can also be useful in RP ?

Answer 12

PDE5 inhibitors decrease severity of RP and may heal ulcers

ex. sildenafil, vardenafil, tadalafil

Question 13

Only consider PDE5 inhibitors or Bosentan in what case?

Answer 13

severe secondary RP

Question 14

How is RP affected in pregnancy?

Answer 14

primary and secondary RP usually decreases in frequency and severity during pregnancy and for at least a few months after delivery

Question 15

Can use _______ in pregnancy

Answer 15

nifedipine if previous clear benefit has been experienced with 30mg XL

*NOTE: nifedipine can be used in pregnancy but is NOT approved for use during pregnancy in Canada

Question 16

What should you tell patient while on nifedipine?

Answer 16

only decreases symptoms and not complications such as digital ulcers

Question 17

How do you handle RP in breastfeeding women?

Answer 17

• non-pharms
• avoid meds if possible
• CCBs go through milk but in small amounts
• Can use nifedipine in breastfeeding

Question 18

What is most likely to be reduced with effective drug treatment?

Answer 18

frequency of attacks

Question 19

What are risks for RP ?

Answer 19

female gender, age > 30, repetitive damage to arteries and nerves, hypothyroidism or SLE