Primary Raynaud's Phenomenon When Nifedipine or Amlodipine Has Not Controlled Attack Frequency

In primary Raynaud's phenomenon, a calcium channel blocker is the standard first-line oral treatment. When that course does not adequately reduce vasospastic attack frequency, the clinical question becomes: what is the appropriate next step?

The Failure Condition

The previous treatment — nifedipine (sustained release) or amlodipine — did not achieve the target of reduction in frequency of Raynaud's phenomenon attacks. This unmet therapeutic goal is the trigger for escalation to the next protocol line.

Second-Line Approach

The next step draws on agents from different pharmacological classes; among these, phosphodiesterase type 5 (PDE5) inhibitors are highlighted in the evidence base as a notable advance for this stage.

The clinical objectives at this line include reducing the frequency, severity and duration of attacks and improvement in the Raynaud's Condition Score. The specific agents, their order of use, and applicable guidance are contained in the full structured regimen.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1177/1759720X17740074

For the practicing rheumatologist, PDE5 inhibitors are therefore probably the most important recent advance in the treatment of ‘uncomplicated’ RP.
The evidence base for other oral therapies for RP is very weak, other drugs sometimes prescribed include angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists, α blockers, nitrates, and the selective serotonin receptor uptake inhibitor fluoxetine.
Fluoxetine has the advantage of not being associated with same vasodilatory side effects as the other drugs mentioned above and may therefore be beneficial in patients intolerant to other therapies.
PDE5 inhibitors conferred benefit in terms of the mean Raynaud’s Condition Score which decreased, the daily frequency of RP attacks which decreased and the daily duration of RP attacks which decreased.
12 weeks’ treatment with losartan conferred benefit in terms of frequency and severity of RP attacks (more so in patients with PRP).
Frequency and severity of attacks fell on fluoxetine and the authors concluded that larger and placebo-controlled trials were indicated.

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