Pharmacotherapy Options in the Management of Raynaud's Phenomenon

Abstract

Purpose of review: Multiple classes of medications have been studied for the treatment of Raynaud's phenomenon (RP) with or without digital ischemia. The goal of this review is to discuss the outcomes of recent studies and to report on our approach to the management of RP in light of the available evidence.

Recent findings: Comparing treatments for RP remains a challenge as efficacy endpoint vary widely among trials. While calcium channel blockers are used first-line in the pharmacologic management of RP, phosphodiesterase 5 inhibitors have also been shown to be beneficial in reducing symptoms. In the setting of digital ischemia, administration of intravenous prostanoids is the standard of care. Bosentan has shown benefit in the prevention of future ulcers in patients with scleroderma. Botulinum toxin therapy was ineffective in a clinical trial involving scleroderma patients; more controlled studies are needed in other subsets of patients. Digital sympathectomy may be beneficial in cases of critical digital ischemia, though recurrence of symptoms is common.

Summary: Comparative effectiveness studies are needed to determine which therapeutic interventions are most beneficial in patients with RP. Based on the available evidence, we start with CCBs and add a phosphodiesterase inhibitor if symptoms are not controlled, or intravenous prostacyclin in the setting of severe critical digital ischemia. We may additionally add an endothelial receptor antagonist in cases of recurrent digital ulcers. A surgical sympathectomy may be used in refractory cases of digital ischemia. A digital block may also be a less invasive, but temporary, intervention allowing for titration of medical therapy.

Keywords: Raynaud’s; outcomes; procedures; review; scleroderma; treatment.

Figure 1.. Our treatment approach for Raynaud’s phenomenon with or without digital ischemia

Figure 1. Our management approach. We start with calcium channel blockers, and add a phosphodiesterase 5 inhibitor for refractory RP symptoms or digital ulcers. If patients continue to have an inadequate response, we will add intravenous prostacyclins and ultimately consider sympathectomy. In situations of critical digital ischemia in which there is imminent threat of digit loss, we will proceed straight to the addition of intravenous prostacyclins onto therapy with calcium channel blockers and will consider digital sympathectomy. In cases of chronic, recurrent, digit ulcers despite prostacyclins therapy, we will add bosentan. *Botulinum toxin injection may also be considered.