Raynaud’s phenomenon

When is it serious?Neil McHugh

Bath Clinic June 2011

Raynaud’s phenomenonMaurice Raynaud (1834 – 1881)

De l'asphyxie locale et de la gangrène symétrique des

extrémités.

Doctoral thesis, published February 25, 1862.

Clinical features or Raynaud’s

Primarily affects fingers Can affect toes, thumbs,

nipples, nose, earlobes Episodes precipitated by

cold exposure and emotional stress

Episodes accompanied by pain +/- numbness

Pulses present Necrosis / tissue damage

suggestive of secondary cause

Initial ischaemia

Pallor

Cyanotic phase

Blue

Hyperaemic phase

Red / purple

Definition of RP

Definite repetitive episodes of biphasic

colour change (at least 2 of pallor, cyanosis, erythema), in either cold or normal environment

Pathogenesis

Causes Primary (~10-15% of healthy population, female

predominance) Secondary

Drugs e.g. Beta blockers Connective tissue disorders e.g. systemic sclerosis Eating disorders Haematological e.g. cold agglutinins Vascular occlusion e.g. vasculitis, thoracic outlet

obstruction, Buerger’s disease Occupation e.g. vibrating tool use Others e.g. hypothyroidism, carpal tunnel syndrome

Is it seconday Raynaud’s? History

Severity, age of onset, gender, symptoms of CTD etc

Clinical examination Radial pulses Skin changes Nailfold changes Joint disease Carpal Tunnel Syndrome

Laboratory investigations FBC, U&E, LFT, CRP, TSH Autoimmune profile Nailfold capillaroscopy Infrared thermography

Systemic sclerosis

Laser Speckle Contrast Imaging

Healthy control Systemic sclerosis

Management General measures

Raynaud’s and Scleroderma Association www.raynauds.org.uk

Scleroderma Society Sclerodermasociety.co.uk

Arthritis Research UK (formerly ARC) www.arthritisresearchuk.org

Maintenance of core temperature Avoidance of cold exposure Cessation of vasoconstrictive Rx e.g. B blockers Gloves (heated) Smoking cessation

Promoting vasodilation Calcium channel blockers

Dihydropyridine Nifedipine better than amlodipine

Nitrates Transdermal or oral

Prostaglandins IV (disappointing results with oral preparation)

Phosphodiesterase V inhibitors Under investigation. Remain expensive.

Preventing vasoconstriction ACEi and ARBs

e.g. losartan May be better in primary RP

Alpha adrenoceptor blockade e.g. prazosin

SSRIs e.g. fluoxetine May be better in primary Raynaud’s

Endothelin receptor antagonists e.g. bosentan Reserved for use in CTD

Novel treatments Rho kinase inhibitors

Responsible for cold-induced expression of alpha-2 adrenoceptors

Statins In part due to Rho kinase inhibition

Antiplatelet treatments? Current trial at RNHRD (for primary and

secondary Raynaud’s)