From the Guidelines
Calcium channel blockers (CCBs) are considered first-line pharmacological therapy for Raynaud's phenomenon, with nifedipine being the most commonly prescribed CCB for this condition. According to the most recent and highest quality study, a 2023 review in Nature Reviews Rheumatology 1, nifedipine has some clinical benefit, low cost, and acceptable adverse effects, making it a suitable first-line treatment. Other CCBs, primarily the dihydropyridine type, can be considered if there is a lack of benefit from or tolerability of nifedipine.
Key Points to Consider
- Nifedipine is typically started at 10-20 mg three times daily or 30-60 mg once daily in extended-release form.
- Other CCBs like amlodipine (5-10 mg daily) and diltiazem (30-120 mg three times daily) may also be effective.
- Treatment is usually initiated during the cold season and may be discontinued during warmer months.
- Before starting medication, patients should first try conservative measures such as keeping the whole body warm, avoiding triggers (cold exposure, emotional stress, caffeine, smoking), and using insulated gloves or hand warmers.
- CCBs work by blocking calcium influx into vascular smooth muscle cells, promoting vasodilation of peripheral blood vessels and improving blood flow to the digits.
- Side effects may include headache, dizziness, flushing, and ankle edema.
- For patients who don't respond adequately to CCBs, second-line options include phosphodiesterase-5 inhibitors, topical nitrates, or prostacyclin analogs, as supported by a 2017 update of EULAR recommendations for the treatment of systemic sclerosis 1.
From the Research
Treatment of Raynaud's Phenomenon
- Calcium channel blockers (CCBs) are often used as a first-line treatment for Raynaud's phenomenon, as they cause arteriolar vasodilation and increase peripheral blood flow 2, 3.
- Studies have shown that CCBs, such as nifedipine and diltiazem, can produce subjective improvement in 60 to 90% of cases, with a decrease in the frequency of vasospastic episodes 2, 3.
- Patients without underlying vascular disease tend to respond more readily to CCB therapy than those with scleroderma or other underlying conditions 2, 3.
Efficacy and Safety of CCBs
- Nifedipine has been shown to be an effective short-term therapy for most patients with Raynaud's phenomenon, with moderate or marked subjective improvement occurring in 60% of patients 2.
- Adverse effects of CCBs are generally mild, with headache and peripheral edema being common side effects 2, 4.
- Newer second-generation dihydropyridines, such as amlodipine and felodipine, may be associated with fewer adverse effects and are also effective in treating Raynaud's phenomenon 4.
Alternative Therapies
- In some cases, CCBs may be ineffective, and alternative therapies such as endothelin antagonists, phosphodiesterase-5 inhibitors, and botulinum toxin may be explored 5.
- These newer therapies may provide effective treatment options for patients with severe symptoms or intolerance to available therapies 5.