From the Guidelines
Patients with Raynaud's phenomenon who have features suggesting secondary Raynaud's or complications requiring specialist management should be referred to a rheumatologist or a specialist with experience in vasospastic disorders. These features include onset after age 30, asymmetric or severe symptoms, tissue damage (digital ulcers, gangrene), abnormal capillaroscopy findings, or positive autoantibodies (ANA, anti-centromere, anti-Scl-70) 1. Refer patients with symptoms suggestive of connective tissue diseases like systemic sclerosis, systemic lupus erythematosus, or inflammatory myopathies, as these conditions often require immunosuppressive therapy. Patients with primary Raynaud's who fail conservative measures (keeping warm, smoking cessation) and first-line medications (calcium channel blockers like nifedipine 30-60mg daily or amlodipine 5-10mg daily) should also be referred. Consider urgent referral for patients with critical digital ischemia, as they may need hospitalization, intravenous prostacyclin analogs, or surgical intervention. The rationale for these referrals is that secondary Raynaud's often indicates underlying systemic disease requiring specific treatment, and severe cases may lead to permanent tissue damage if not managed appropriately by specialists with experience in vasospastic disorders. Key factors to consider when deciding on referral include:
- Age of onset
- Symptom severity and asymmetry
- Presence of tissue damage or abnormal capillaroscopy findings
- Presence of positive autoantibodies
- Failure of conservative measures and first-line medications
- Presence of symptoms suggestive of connective tissue diseases. Early referral to a specialist is crucial to prevent long-term morbidity and mortality associated with untreated or undertreated Raynaud's phenomenon, as highlighted by the importance of early diagnosis and treatment in patients with rheumatoid arthritis 1.
From the Research
Patients Requiring Referral
The following patients with Raynaud's disease may require referral:
- Those with secondary Raynaud's, which is associated with other diseases or conditions, such as connective tissue diseases, scleroderma, and systemic lupus erythematosus 2
- Patients with severe or refractory Raynaud's phenomenon, who may require second-line treatments such as sildenafil, tadalafil, and/or iloprost IV 3
- Individuals with digital ulcers, who may require treatment with bosentan, sildenafil, tadalafil, and/or iloprost IV to promote healing and prevent further ulcers 3, 4
- Patients who have failed medical management and may benefit from alternative treatments, such as botulinum toxin A injections 5
- Those with systemic sclerosis or mixed connective tissue disease and severe Raynaud's phenomenon/critical ischemia or active digital ulcers, who may require iloprost infusion through an elastomeric pump 4
Characteristics of Patients Requiring Referral
Patients who may require referral often have: