Norvasc (Amlodipine) for Raynaud's Phenomenon
Nifedipine, not amlodipine (Norvasc), is the recommended first-line calcium channel blocker for Raynaud's phenomenon, as it has the strongest evidence base and is specifically endorsed by major guidelines. 1
Why Nifedipine Over Amlodipine
The European League Against Rheumatism specifically recommends nifedipine as first-line pharmacotherapy for both primary and secondary Raynaud's, citing its proven efficacy in reducing frequency and severity of attacks with acceptable adverse effects and low cost 1
Nifedipine reduces vasospastic episodes from approximately 14.7 per two weeks to 10.8 episodes, with 60% of patients experiencing moderate to marked improvement compared to only 13% on placebo 2
While amlodipine is a dihydropyridine calcium channel blocker like nifedipine, the clinical trial evidence and guideline recommendations are overwhelmingly specific to nifedipine 1, 2
Other dihydropyridine calcium channel blockers can be considered only if there is lack of benefit from or poor tolerability of nifedipine 3
Treatment Algorithm for Raynaud's Phenomenon
Step 1: Non-Pharmacological Management (All Patients)
Implement trigger avoidance before or alongside any pharmacotherapy, including cold avoidance with proper warm clothing, hand/foot warmers, mittens, and insulated footwear 1, 3
Mandatory smoking cessation, as nicotine directly worsens vasospasm and undermines all treatment efforts 1
Discontinue triggering medications including beta-blockers, ergot alkaloids, bleomycin, and clonidine 1
Stress management techniques and avoiding vibration injury/repetitive hand trauma 1
Step 2: First-Line Pharmacotherapy
Start nifedipine (not amlodipine) for patients whose symptoms affect quality of life despite non-pharmacological measures 1, 3
Nifedipine benefits approximately two-thirds of patients with both primary and secondary Raynaud's 3
Use long-acting "retard" preparations to reduce adverse effects like ankle swelling, headache, and flushing 4
Step 3: Second-Line Therapy (Inadequate Response to Nifedipine)
Add or switch to phosphodiesterase-5 inhibitors (sildenafil or tadalafil) when calcium channel blockers provide inadequate response 1, 3
PDE5 inhibitors effectively reduce frequency, duration, and severity of attacks 3
These agents are particularly valuable if digital ulcers are present, as they promote both healing and prevention 1, 3
Step 4: Third-Line Therapy (Severe Refractory Disease)
Intravenous iloprost (prostacyclin analogue) for severe Raynaud's unresponsive to oral therapies, particularly effective for healing digital ulcers 1, 3
Bosentan (endothelin receptor antagonist) specifically for preventing new digital ulcers, especially in patients with ≥4 existing ulcers 1, 3
Critical Pitfalls to Avoid
Always evaluate for systemic sclerosis and other connective tissue diseases, as delayed diagnosis leads to digital ulcers and poor outcomes 1
Do not continue beta-blockers or other vasoconstrictors, as they will undermine all treatment efforts 1
Secondary Raynaud's requires more aggressive therapy—delaying escalation can lead to digital ulcers, gangrene, and potential amputation 1, 3
Severe, painful episodes with digital ulceration are red flags for secondary Raynaud's requiring urgent workup 3
Bottom Line on Amlodipine
While amlodipine (Norvasc) is theoretically a reasonable alternative as a dihydropyridine calcium channel blocker, the evidence-based recommendation is to use nifedipine specifically 1, 2. If nifedipine is not tolerated, then other dihydropyridines including amlodipine could be considered 3, but this represents a deviation from guideline-recommended therapy without the same level of supporting evidence.