A 34-year-old woman with no significant medical history presents to her primary care physician complaining of color changes in her fingertips. She states she has been experiencing significant discomfort in her fingertips especially during the winter months associated with intermittent numbness and tingling. She has tried to put on thick gloves whenever she is outside in the cold weather which does not help much. When she has these episodes, her fingertips turn into a whitish color followed by a purple discoloration before they are back to normal. She denies any other symptoms including chest pain, dyspnea, nausea, heartburn, rash, joint pain, muscle pain, weakness, or hair loss. On physical examination, her fingers are pink and warm with normal capillary refill. There is no evidence of ulceration, open lesions, or skin thickening. Screening lab tests do not show significant findings. The patient is given education on lifestyle modification and is started on amlodipine 5mg daily. The patient returns in 2 months stating her symptoms have only improved slightly.
B) Increase amlodipine dosage to 10mg daily and monitor blood pressure
This patient presents with a classic picture of Raynaud phenomenon (RP), which is a common complaint in young female patients around the age of 30. Some patients have a strong family history of Raynaud phenomenon which should be explored. RP could be primary or secondary process. Diagnostic tests include nailfold capillaroscopy, and lab tests including complete blood count, renal and liver panel, antinuclear antibody, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), thyroid function tests should be obtained. This patient does not present with symptoms concerning for secondary Raynaud phenomenon at this time (e.g., lupus, systemic sclerosis, vasculitis). If there were concern for secondary Raynaud phenomenon, an anti-nuclear antibody (ANA) could be ordered, and depending on the pattern and titer, more specific auto-antibodies such as anticentromere and anti-scl-70 should be ordered to evaluate for systemic sclerosis. Additional workup including chest x-ray and echocardiogram should be considered if a patient presented with concerning systemic symptoms.
Answer choice A: Add low dose losartan, is incorrect. Second line agents such as PDE-5 inhibitors, topical nitrates, or angiotensin receptor blockers (ARBs) such as losartan are recommended for cold-induced Raynaud phenomenon when a dihydropyridine calcium channel blocker such as amlodipine does not improve a patient’s symptoms. The patient was started on low dose amlodipine 5mg which can be increased to 10mg once daily and monitored for signs of improvement. If the patient does not experience relief within 6-8 weeks, then a second-line agent should be either used as a replacement therapy or in combination with the calcium channel blocker.
Answer choice C: Referral to surgery for evaluation, is incorrect. Surgery referral is indicated when there is severe ulceration or open lesions needing surgical debridement which are not present in this patient.
Answer choice D: Start low dose fluoxetine, is incorrect. Selective serotonin reuptake inhibitors are recommended per the American College of Rheumatology for patients who have anxiety-induced Raynaud phenomenon. Other treatment options used for patients in this category include cognitive behavioral therapy and acupuncture. The patient above describes a clear association of her symptoms with cold weather. Thus, fluoxetine is not indicated.
Answer choice E: Switch amlodipine to a different calcium channel blocker (CCB) such as verapamil, is incorrect. Dihydropyridine CCBs such as amlodipine and nifedipine are preferred. Non-dihydropyridine CCBs such as diltiazem and verapamil do not have sufficient evidence.
Key Learning Point
A dihydropyridine calcium channel blocker (CCB) is the first line treatment for Raynaud phenomenon. Second line agents should be considered when CCB does not provide relief, and the specific agent to be used should depend on whether the patient’s symptoms are cold induced, or anxiety induced.
