Do Bulgarian physicians use a different algorithm that recommends hydroxychloroquine as first‑line therapy for Raynaud’s phenomenon in a 39‑year‑old patient with abnormal nail‑fold capillaroscopy, low‑titer Th/To and PM‑Scl‑75 antibodies, no visceral involvement, normal inflammatory markers and creatine kinase, and treated vitamin D deficiency?

Bulgarian Treatment Algorithms for Raynaud's Phenomenon

No, Bulgarian physicians should follow the same international evidence-based guidelines that recommend dihydropyridine calcium channel blockers (specifically nifedipine) as first-line pharmacological therapy for Raynaud's phenomenon, not hydroxychloroquine. There is no country-specific deviation in treatment algorithms for this condition. 1

Standard First-Line Treatment Across All Countries

The European League Against Rheumatism (EULAR) provides Grade A recommendations that apply universally across all European countries, including Bulgaria, stating that dihydropyridine-type calcium channel blockers (usually oral nifedipine) should be considered as first-line therapy for systemic sclerosis-related Raynaud's phenomenon. 1

• Nifedipine extended-release should be initiated at 30 mg once daily and titrated over 7-14 days to a target of 60-90 mg daily based on therapeutic response and tolerability. 2
• Meta-analyses demonstrate that nifedipine reduces both the frequency and severity of Raynaud's attacks in approximately two-thirds of patients. 1, 2

Why Hydroxychloroquine Is Not Indicated

Hydroxychloroquine has no role in the treatment of Raynaud's phenomenon or systemic sclerosis-related vascular complications. The evidence base is clear on this point:

• The 2019 EULAR recommendations for rheumatoid arthritis explicitly state that hydroxychloroquine has "only weak clinical and no structural efficacy" even in RA, and it has been relegated to a limited role. 1
• None of the international guidelines for systemic sclerosis or Raynaud's phenomenon mention hydroxychloroquine as a treatment option. 1, 3, 2, 4
• Hydroxychloroquine is an antimalarial/immunomodulatory agent used primarily for lupus and rheumatoid arthritis, not for vasospastic or vascular complications. 1

Evidence-Based Treatment Algorithm for This Patient

Given the clinical presentation (39-year-old with abnormal capillaroscopy, positive autoantibodies, and Raynaud's phenomenon suggesting early systemic sclerosis):

Step 1: First-Line Therapy

• Initiate nifedipine extended-release 30 mg daily, titrating to 60-90 mg daily as tolerated. 1, 2
• Cold avoidance strategies, smoking cessation, and trigger avoidance are essential non-pharmacological measures. 1, 4

Step 2: Second-Line Therapy (if inadequate response to calcium channel blockers)

• Add a phosphodiesterase-5 inhibitor (sildenafil or tadalafil 20 mg every other day) to the calcium channel blocker regimen. 1, 3
• PDE-5 inhibitors reduce frequency, duration, and severity of Raynaud's attacks and are particularly valuable if digital ulcers develop. 1, 3

Step 3: Third-Line Therapy (for severe, refractory disease)

• Consider intravenous iloprost for severe Raynaud's phenomenon unresponsive to oral therapies. 1, 3
• Iloprost is the only prostacyclin analogue with proven efficacy for systemic sclerosis-related Raynaud's phenomenon. 1

Step 4: Digital Ulcer Prevention (if ≥4 digital ulcers develop)

• Add bosentan 62.5 mg twice daily for 4 weeks, then 125 mg twice daily, specifically for prevention of new digital ulcers. 1, 3, 2
• Note that bosentan prevents new ulcers but does not heal existing ones. 1, 3

Clinical Context of This Patient

The presence of abnormal nailfold capillaroscopy with positive Th/To and PM-Scl-75 antibodies strongly suggests early systemic sclerosis, making this secondary Raynaud's phenomenon that requires aggressive vasodilator therapy, not immunomodulation with hydroxychloroquine. 5, 6, 7

• Abnormal capillaroscopy patterns (giant capillaries, microhemorrhages, capillary loss) predict progression from isolated Raynaud's to systemic sclerosis spectrum disorders. 6, 8
• The scleroderma pattern on capillaroscopy is a crucial diagnostic finding that indicates underlying rheumatic disease. 7, 8
• Early initiation of appropriate vasodilator therapy is critical to prevent digital ulcers and other vascular complications. 1, 3

Common Pitfall to Avoid

The most significant error would be prescribing hydroxychloroquine instead of nifedipine, as this would delay appropriate vasodilator therapy and potentially lead to digital ulcers, gangrene, or other serious vascular complications. 3, 4

• Delays in appropriate treatment for secondary Raynaud's phenomenon are a major preventable cause of poor outcomes. 2
• Missing the distinction between immunomodulatory therapy (which hydroxychloroquine provides) and vasodilator therapy (which this patient needs) can result in irreversible digital ischemia. 3

There is no evidence-based rationale for using hydroxychloroquine as first-line therapy for Raynaud's phenomenon in any country, including Bulgaria. All European physicians should follow the same EULAR guidelines. 1