What are the treatment options for painful Raynaud's (Raynaud's disease) phenomenon?

From the Guidelines

For painful Raynaud's phenomenon, dihydropyridine-type calcium antagonists, specifically oral nifedipine, should be used as first-line therapy. This recommendation is based on the most recent and highest quality evidence from the 2023 update of the EULAR recommendations for the treatment of systemic sclerosis 1. Nifedipine has been shown to have clinical benefit, low cost, and acceptable adverse effects, making it a suitable first-line treatment option 1.

Treatment Options

• Dihydropyridine-type calcium antagonists, such as nifedipine, are the preferred first-line treatment for Raynaud's phenomenon 1
• Phosphodiesterase-5 inhibitors, such as sildenafil, can be considered for treatment of Raynaud's phenomenon, particularly in severe cases 1
• Intravenous iloprost may be considered for severe Raynaud's phenomenon following failure of oral therapy 1
• Practical measures, such as keeping extremities warm, avoiding cold exposure, reducing stress, and stopping smoking, should be combined with medication to maximize effectiveness 1

Additional Considerations

• Bosentan should be considered for reduction of new digital ulcers in systemic sclerosis, but its use is not specifically recommended for Raynaud's phenomenon 1
• Other medications, such as alpha-blockers and ARBs, may be used when other treatments fail, but their effectiveness is not as well established 1
• Physical therapy, biofeedback, and laser treatment may be used to stimulate blood flow and prevent symptoms, but their effectiveness is still being studied 1

From the Research

Treatment Options for Painful Raynaud's Phenomenon

• The primary goal of therapy is to reduce the frequency and intensity of Raynaud's attacks and to minimize the related morbidity rather than to cure the underlying condition 2.
• Calcium channel blockers are currently the most prescribed and studied medications for this purpose, with nifedipine and diltiazem producing subjective improvement in 60 to 90% of cases 3, 4.
• Phosphodiesterase inhibitors (e.g., sildenafil) can also improve RP symptoms and ulcer healing, whereas endothelin-1 receptor antagonists (e.g., bosentan) are mainly considered treatment options in secondary prevention for patients with digital skin ulcers related to systemic sclerosis 5, 2.
• Intravenously administered prostacyclin analogue iloprost can reduce the frequency and severity of RP attacks and is considered a second-line therapy in patients with markedly impaired quality of life, critical digital ischaemia and skin ulcers who are at risk for substantial tissue loss and amputation 5, 2.
• Other treatment options include:
  • Topical nitrates
  • α-antagonists
  • Angiotensin receptor blockers
  • Selective serotonin reuptake inhibitors
  • Pentoxifylline
  • Antiplatelet therapy with low-dose aspirin
  • Anticoagulant therapy
  • Chemical and/or surgical sympathectomy
  • Digital block 5, 6, 2

Pharmacologic Approach

• Dihydropyridine calcium channel blockers are by far the most commonly studied and prescribed class of agents for the treatment of Raynaud's phenomenon 6.
• More expensive second-line agents, such as phosphodiesterase-5 inhibitors, endothelin receptor antagonists, and intravenous prostanoids, are reserved for refractory cases of secondary Raynaud's phenomenon with severe digital ischemia leading to ulceration or gangrene 6.
• Comparative effectiveness studies are needed to determine which therapeutic interventions are most beneficial in patients with RP 5.

Alternative Treatment Options

• Botulinum toxin therapy was ineffective in a clinical trial involving scleroderma patients; more controlled studies are needed in other subsets of patients 5.
• Digital sympathectomy may be beneficial in cases of critical digital ischemia, though recurrence of symptoms is common 5, 6.