Raynaud’s phenomenon

When is it serious?

Neil McHugh

Bath Clinic June 2011

Raynaud’s phenomenon

Maurice 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)