Raynaud’s phenomenon When is it serious? Neil McHugh Bath Clinic June 2011.
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Transcript of Raynaud’s phenomenon When is it serious? Neil McHugh Bath Clinic June 2011.
Raynaud’s phenomenon
When is it serious?
Neil McHugh
Bath Clinic June 2011
Raynaud’s phenomenon
Maurice Raynaud (1834 – 1881)
De l'asphyxie locale et de la gangrène symétrique des
extrémités.
Doctoral thesis, published February 25, 1862.
Clinical features or Raynaud’s
Primarily affects fingers Can affect toes, thumbs,
nipples, nose, earlobes Episodes precipitated by
cold exposure and emotional stress
Episodes accompanied by pain +/- numbness
Pulses present Necrosis / tissue damage
suggestive of secondary cause
Initial ischaemia
Pallor
Cyanotic phase
Blue
Hyperaemic phase
Red / purple
Definition of RP
Definite
repetitive episodes of biphasic colour change (at least 2 of pallor, cyanosis, erythema), in either cold or normal environment
Pathogenesis
Causes
Primary (~10-15% of healthy population, female predominance)
Secondary Drugs e.g. Beta blockers Connective tissue disorders e.g. systemic sclerosis Eating disorders Haematological e.g. cold agglutinins Vascular occlusion e.g. vasculitis, thoracic outlet
obstruction, Buerger’s disease Occupation e.g. vibrating tool use Others e.g. hypothyroidism, carpal tunnel syndrome
Is it seconday Raynaud’s? History
Severity, age of onset, gender, symptoms of CTD etc
Clinical examination Radial pulses Skin changes Nailfold changes Joint disease Carpal Tunnel Syndrome
Laboratory investigations FBC, U&E, LFT, CRP, TSH Autoimmune profile Nailfold capillaroscopy Infrared thermography
Systemic sclerosis
Laser Speckle Contrast Imaging
Healthy control Systemic sclerosis
Management
General measures Raynaud’s and Scleroderma Association
www.raynauds.org.uk Scleroderma Society
Sclerodermasociety.co.uk Arthritis Research UK (formerly ARC)
www.arthritisresearchuk.org Maintenance of core temperature Avoidance of cold exposure Cessation of vasoconstrictive Rx e.g. B blockers Gloves (heated) Smoking cessation
Promoting vasodilation
Calcium channel blockers Dihydropyridine
Nifedipine better than amlodipine Nitrates
Transdermal or oral Prostaglandins
IV (disappointing results with oral preparation) Phosphodiesterase V inhibitors
Under investigation. Remain expensive.
Preventing vasoconstriction
ACEi and ARBs e.g. losartan May be better in primary RP
Alpha adrenoceptor blockade e.g. prazosin
SSRIs e.g. fluoxetine May be better in primary Raynaud’s
Endothelin receptor antagonists e.g. bosentan Reserved for use in CTD
Novel treatments
Rho kinase inhibitors Responsible for cold-induced expression of alpha-
2 adrenoceptors Statins
In part due to Rho kinase inhibition Antiplatelet treatments?
Current trial at RNHRD (for primary and secondary Raynaud’s)