Current therapies for Raynaud’s
Many treatments are available. Only one drug, Nifedipine, is licenced for Raynaud’s. Patients sometimes find the side effects of this drug intolerable. Therefore one has to, as in other uncommon conditions, use drugs off licence. It is important to have a variety of drugs with which to alleviate the symptoms. Many patients with Raynaud’s like to try natural products before using conventional drugs. The response to any individual therapy for Raynaud’s varies with respect to how well a drug works and side effects and it is always worth trying one or more of the drugs within each of the groups listed below. Each drug should be taken for at least 2 weeks and then stop for 3 days before changing from one drug to another. To avoid side effects, try starting with a low dose, taken at night for a few days, then build up steadily to the full dose.
Calcium channel blockers
• Nifedipine retard (Adalat) 10mg twice a day increasing to 20mg twice a day
• Nifedipine LA 30mg daily
• Amlodipine 5-10mg daily
• Diltiazem 60mg three times a day
Angiotensin converting enzyme inhibitors
Usually started at low doses to prevent any blood pressure problems
• Captopril 6.25mg (test dose very small), then starting at a dose of 12.5mg twice a day (max 25mg twice a day)
• Enalapril 5mg starting dose, increasing to 10mg-20mg daily
• Lisinopril 2.5mg starting dose, increasing to 10mg-20mg daily
• Quinapril 5mg starting dose increasing to 20mg daily
Angiotensin II receptor antagonists
• Losartan 25mg daily, increasing to 50mg daily
• Valsartan 40mg daily, increasing to 80mg daily
Serotonin re-uptake antagonists
• Fluoxetine 20-40mg daily. Note this drug is also used to treat depression in other patients. Its use in Raynaud’s is to dilate the peripheral blood vessels Other members of the group that can be tried
are:
• Sertraline 50mg daily increasing to a maximum of 200mg (doses of 150mg or greater should not be used for more than 8 weeks)
• Paroxetine 20mg daily increasing by 10mg per week to a max of 40mg daily
Other drugs and alternative treatments
• GTN patches: for the acute situation. A dose of 0.2mg/hr (5mg patch) to start with, increasing to 0.4mg/hr (10mg patch) if required. There must be a 12 hour period each day, free of drug to prevent nitrate tolerance (the drug no longer working)
Anti oxidants
These drugs are used to prevent damage to blood vessels
• Vitamin E 100iu-400iu daily (iu = international units, which are used as a measurement in a similar way to mg)
• Vitamin C 500mg-1000mg daily
Best to take both for maximum antioxidant effect
Increase prostacyclin by:
Evening primrose oil or fish oils are used (note any make will do). You need to look at the gamolenic acid (GLA) content on the bottle of these capsules. A dose of 320mg per day is recommended. Most capsules of evening primrose oil etc., only contain approximately 40mg. Therefore one would need to take 4 capsules twice a day. Generic GLA (320mg per day) or another alternative is OMACOR (2000-4000mg per day) can be prescribed. Other options are:
• Maxepa (concentrated fish oils) – dose is 5 capsules twice a day
• Epogam (gamolenic acid in evening primrose oil) 40mg – dose is 4 capsules twice a day.
In addition you can now obtain high strength capsules in some supermarkets and health food stores.
Intravenous Treatments
Prostacyclin is a natural substance produced by blood vessels that is deficient in cases of Raynaud's. It can be given by intravenous infusion in severe cases of Raynaud's or when there are complications. Treatment is given in hospital.
• Iloprost (a nebulised version is also available)
• Flolan - similar to iloprost.
Dr Chris Denton,
Royal Free Hospital, London
