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)

Jamieson, Barbara

Purdon, Michael

Tagliarino, Heather

University of Missouri: MOspace

VOL 54, NO 6 / JUNE 2005 553w w w. j f p o n l i n e . c o mCLINICAL INQUIRIESWhat is the evaluation and treatmentstrategy for Raynaud’s phenomenon?■ Evidence summaryRaynaud’s phenomenon is diagnosed bya history of cold temperatures or emo-tional stress precipitating episodic digitalartery vasospasm, according to expertopinion. This presents as well-demarcat-ed digital pallor and cyanosis, often fol-lowed by reactive hyperemia occurring15 to 20 minutes after rewarming.1,2 Noreliable office test confirms the diagnosis.By definition, primary Raynaud’s phe-nomenon occurs in the absence of associ-ated diseases and is considered an exag-gerated vasoconstrictive response to cold.It must be distinguished from normalmottling of the digits in response to coldtemperatures, effects of vasoconstrictivemedications, environmental injury (frost-bite, use of vibrating tools), neuropathy,and thoracic outlet syndrome.1,2 Expertsdiffer on whether laboratory evaluationwith erythrocyte sedimentation rate andan antinuclear antibody test is necessaryfor patients with primary Raynaud’s phe-nomenon.1,3Patients with secondary Raynaud’sphenomenon have an underlying causeor disease, such as scleroderma or sys-temic lupus erythematosis.2 The findingof distorted capillaries in the nail foldsusing an ophthalmoscope set at 40+diopter magnification is the best predic-tor of an associated connective-tissue dis-ease.4 A cold-water challenge to triggerHeather Tagliarino, MDSwedish Medical Center, Seattle; University of Washington, SeattleMichael Purdon, MDSwedish Medical Center, SeattleBarbara Jamieson, MLSMedical College of Wisconsin, MilwaukeeC L I N I C A L C O M M E N T A R YReserve pharmacotherapy for cases that are resistant to conservative measuresRaynaud’s phenomenon is one of those clinicalsyndromes that stirs the desire to find an exoticexplanation, such as systemic lupus erythemato-sus, but most often yields less glamorous results.Usually I must tell patients that I can’t explain thecause and recommend that they keep their handsas warm as possible to avoid the symptoms. Ihave learned to discipline myself over the years topursue a connective tissue cause only when othersigns or symptoms of such a disease are also pres-ent. The use of the ophthalmoscope at high powerto look for distorted nail-fold capillary loops is ahelpful pearl.I reserve pharmacotherapy for cases that areresistant to conservative measures due to the costand side effects of the drug options. Grant Hoekzema, MDMercy Family Medicine Residency, St. Louis, MoRaynaud’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 includesconservative measures such as the use of gloves,cold avoidance, and rapid rewarming (SOR: C, based on expert opinion); in refractorycases, the vasodilatory agents nifedipine or prazosin alleviate symptoms (SOR: A for both,based on multiple randomized controlled trials) (TABLE).E V I D E N C E - B A S E D A N S W E RC O N T I N U E DMedication maybe beneficial forpatients not helpedby conservativemeasures—dressing warmly,wearing gloves,avoiding cold andemotional stress554 VOL 54, NO 6 / JUNE 2005  THE JOURNAL OF FAMILY PRACTICECLINICAL INQUIRIESFAST TRACKan attack of Raynaud’s phenomenon pro-duces inconsistent results and is not rec-ommended. Research tools such as ther-mographic and laser Doppler imagingcan measure digital artery blood flow butare rarely used clinically.1,5 Patients withsecondary Raynaud’s phenomenonshould have a complete blood count, bio-chemistry profile, and urinalysis. Theymay need additional tests as determinedby the nature of their underlying disease.1Conservative management is helpfulfor all patients with Raynaud’s phenome-non, and may be the only treatment need-ed. Experts advise dressing warmly, wear-ing gloves when appropriate, usingabortive strategies such as placing thehands into warm water, and avoiding sud-den cold exposure, emotional stress, andvasoconstrictive agents such as nicotine.6Medication may be helpful for patientswhose symptoms are not controlled withconservative measures. Six randomized,placebo-controlled trials involving 451people with primary Raynaud’s phenome-non demonstrated that nifedipine decreasesthe mean frequency of vasospastic attacks.Three of these trials also showed subjectiveimprovement in symptom severity withnifedipine vs placebo.7 A meta-analysis of 6randomized crossover studies comparednifedipine or nicardipine with placebo in59 patients with secondary Raynaud’s phe-nomenon and underlying systemic sclero-sis. Nifedipine significantly decreased thefrequency and severity of attacks.Nicardipine showed a trend towardsreduced symptoms in 1 trial with only 15patients.8 Another randomized trial com-paring sustained-release nifedipine to place-bo showed a 66% reduction in the numberof attacks in the treatment group at 1 year;19 of the 77 people in the nifedipine groupdropped out of the study, as did 24 of the81 people in the placebo group.9A systematic review of 2 randomizedcontrolled trials with a total of 40 patientsfound prazosin modestly effective in sec-ondary Raynaud’s phenomenon, but itwas less well-tolerated than calcium chan-nel blockers.10 Single, small randomizedcrossover trials showed improved respons-es to both fluoxetine11 and losartan12 whencompared with nifedipine. In general,these medications appear to reduceattacks by 30% to 40%.Small, prospective studies of low-level laser irradiation, palmar sympathec-tomy, and endoscopic thoracic sympa-thectomy show some benefit for patientswith digital ulcers.13–15 A randomized con-trolled trial showed biofeedback wasineffective for voluntary control of digi-tal blood flow for patients withRaynaud’s phenomenon.9Recommendations from othersThe American College of Rheumatologydoes not offer recommendations for thediagnosis or treatment of Raynaud’s phe-nomenon. UpToDate recommends treat-ment with conservative measures; sus-tained-release nifedipine or amlodipinemay be used if these are insufficient.Other vasodilators may be added or sub-stituted in the event of an adverse reac-tion or poor response to the calcium-channel blocker.16T A B L ERECOMMENDATION TREATMENT LEVEL COMMON ADVERSE EFFECTSNifedipine A Lower extremity edema, flushing, headache, dizzinessPrazosin A Dizziness, hypotension, palpitationsConservative C —Primary therapies for Raynaud’s phenomenonw w w. j f p o n l i n e . c o mRaynaud’s phenomenon ▲R E F E R E N C E S1. Bowling JC, Dowd PM. Raynaud’s disease. Lancet2003; 361:2078–2080.2. Wigley FM. Clinical practice. Raynaud’s phenomenon.N Engl J Med 2002; 347:1001–1008.3. Wigley FM. Clinical manifestations and diagnosis ofthe Raynaud phenomenon. UpToDate. Available at:www.uptodate.com. Accessed on May 9, 2005.4. Nagy Z, Czirjak L. Nailfold digital capillaroscopy in 447patients with connective tissue disease and Raynaud'sdisease.  Eur Acad Dermatol Venereol 2004; 18:62–68.5. Clark S, Dunn G, Moore T, Jayson M 4th, King TA,Herrick, AL. Comparison of thermography and laserDoppler imaging in the assessment of Raynaud’s phe-nomenon. Microvasc Res 2003; 66:73–76.6. Brown KM, Middaugh SJ, Haythornthwaite JA, BieloryL. The effects of stress, anxiety, and outdoor tempera-ture on the frequency and severity of Raynaud’sattacks: the Raynaud’s treatment study. J Behav Med2001; 24:137–153.7. Pope J. Raynaud’s phenomenon (primary). Clin Evid2004; 11:1–2.8. Thompson AE, Shea B, Welch B, Fenlon D, Pope J.Calcium-channel blockers for Raynaud’s phenomenonin systemic sclerosis. Arthritis Rheum 2001;44:1841–1847.9. Comparison of sustained-release nifedipine and tem-perature biofeedback for treatment of primaryRaynaud phenomenon. Results from a randomizedclinical trial with 1-year follow-up. Arch Intern Med2000; 160:1101–1108.10. Pope J, Fenlon D, Thompson A, et al. Prazosin forRaynaud’s phenomenon in progressive systemic scle-rosis. Cochrane Database Syst Rev 2000(2):CD000956.11. Coleiro B, Marshall SE, Denton CP, et al. Treatment ofRaynaud’s phenomenon with the selective serotoninreuptake inhibitor fluoxetine. Rheumatol (Oxf) 2001;40:1038–1043.12. Dziadzio M, Denton CP, Smith R, et al. Losartan thera-py for Raynaud's phenomenon and scleroderma: clin-ical and biochemical findings in a fifteen-week, ran-domized, parallel-group, controlled trial. ArthritisRheum 1999; 42:2646–2655.13. al-Awami M, Schillinger M, Gschwandtner ME, MacaT, Haumer M, Minar E. Low level laser treatment of pri-mary and secondary Raynaud’s phenomenon. VASA2001; 30:281–284.14. Tomaino MM, Goitz RJ, Medsger TA. Surgery forischemic pain and Raynaud’s phenomenon in sclero-derma: a description of treatment protocol and evalu-ation of results. Microsurgery 2001; 21:75–79.15. Matsumoto Y, Ueyama T, Endo M, Sasaki H,Kasashima F, Abe Y et al. Endoscopic thoracic sympa-thectomy for Raynaud’s phenomenon. J Vasc Surg2002; 36:57–61.16. Wigley FM. Treatment of the Raynaud phenomenon.UpToDate. Available at: www.uptodate.com. Accessedon May 9, 2005.VOL 54, NO 6 / JUNE 2005 555FAMILYPRACTICETHE JOURNAL OFTHE JOURNAL OF FAMILY PRACTICE uses a simplified rating system system called theStrength of Recommendation Taxonomy(SORT). More detailed information can be found in the  February 2003 issue,“Simplifying the language of patient care,”pages 111–120.Strength of Recommendation (SOR) ratingsare given for key recommendations for readers.SORs should be based on the highest-quality evidence available.A Recommendation based on consistent and good-quality patient–oriented evidence.B Recommendation based on inconsistent or limited-quality patient-oriented evidence.C Recommendation based on consensus, usual practice,opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screeningLevels of evidence determine whether a studymeasuring patient-oriented outcomes is ofgood or limited quality, and whether the resultsare consistent or inconsistent between studies.STUDY QUALITY1—Good-quality, patient-oriented evidence (eg, validated clinical decision rules, systematic reviews and meta-analyses of randomized controlled trials[RCTs] with consistent results, high-quality RCTs, ordiagnostic cohort studies)2—Lower-quality patient-oriented evidence (eg, unvalidated clinical decision rules, lower-quality clinical trials, retrospective cohort studies, case controlstudies, case series)3—Other evidence (eg, consensus guidelines, usual practice, opinion, case series for studies of diagnosis,treatment, prevention, or screening)Consistency across studies Consistent—Most studies found similar or at least coherent conclusions (coherence means that differencesare explainable); or If high-quality and up-to-date systematic reviews or meta-analyses exist, they supportthe recommendationInconsistent—Considerable variation among study findingsand lack of coherence; or If high-quality and up-to-date systematic reviews or meta-analyses exist, they do not find consistent evidence in favor of the recommendationEvidence-based medicine ratings

What is the evaluation and treatment strategy for Raynaud's phenomenon?

Abstract

Similar works

Full text

Available Versions

University of Missouri: MOspace