Management of Raynaud phenomenon if calcium channel blocker treatment has failed

Margaret J. Larché is a professor of medicine in the Division of Rheumatology at McMaster University and director of the Canadian Scleroderma Research Group (CSRG).

What management should be considered in patients with Raynaud phenomenon if treatment with calcium channel blockers has been ineffective?

Once you’ve tried calcium channel blockers and depending on the severity of the Raynaud and whether there are complications, I would escalate the dose of calcium channel blockers to the maximum tolerated.

If either they can’t tolerate the moderate doses, such as 60 mg of a slow-release [formulation] daily, I would move on to a phosphodiesterase inhibitor, such as sildenafil or tadalafil. Again, I would start low and work up in terms of dosing. You could start with, for example, 20 mg once a day of sildenafil and move up to 20 mg tid or 50 mg bid. We are lucky in Canada that we have access to this medication.

Prior to us having access to that medication, we would often use a variety of medications, including angiotensin receptor blockers, alpha blockers, and then we would sometimes use nitrate as a nitrate patch that you would you often use in angina. I used to call this “mini angina of the fingers,” and so we would use a nitrate patch that you’d use in angina.

Finally, if necessary, we’d move on to intravenous therapies such as prostacyclins. That needs a hospital: either a hospital admission or at least a trip to the outpatient department to have this intravenous therapy. Then we can use some surgical approaches, such as sympathectomy, where the anesthetists or surgeons will block the sympathetic chain, or with gangrene, we might need to do amputations if necessary for pain, for analgesia.