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Raynaud's phenomenon

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					 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   Initial ischaemia
 Can affect toes, thumbs,    Pallor
  nipples, nose, earlobes
 Episodes precipitated by
  cold exposure and
  emotional stress            Cyanotic phase
 Episodes accompanied by     Blue
  pain +/- numbness
 Pulses present
 Necrosis / tissue damage
  suggestive of secondary     Hyperaemic phase
  cause                       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)

				
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posted:9/18/2011
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