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Old 10-20-2011
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Drug How to treat Raynaud's

20-year-old college student comes to the clinic concerned about pain in the fingers of her right hand. For the last two winters she has noticed that her fingers turn white when exposed to cold weather. While white, the fingers are painless. However, when she warms her hands her fingers will turn blue or red, at which time they become painful. Because this is a problem with which her mother has suffered for years, she originally decided to ignore the problem. She found she could minimize symptoms by wearing gloves and, on cold days, using hand warmers. Now, however, she is concerned that things have gotten worse. There are two small wounds on the tips of her fingers that worry her. Aside from these symptoms she has no complaints. She denies any arthralgias, dysphagia, chest pain, shortness of breath, or constitutional symptoms. Past medical history is unremarkable. Vital signs are: blood pressure 122/68 mm Hg, pulse 62/min, respirations 20/min, and temperature 37 C (98.6 F). Examination reveals some small ulceration on the tips of her right index and ring fingers, but is otherwise unremarkable. A set of autoimmune antibody assays is ordered. An ANA titer is 1:320, with a speckled pattern. Anticentromere antibodies, U3-RNP antibodies, and anti-RNA polymerase antibodies are positive, while anti-Scl 70 antibodies are negative, as is a P-ANCA. A set of routine laboratory chemistries and a complete blood count are unremarkable. Which of the following is the most appropriate pharmacotherapy for this patientís condition?
A. ACE inhibitor
B. Beta-blocker
C. Calcium-channel blocker, dihydropyridine
D. Calcium-channel blocker, nondihyropyridine
E. Prednisone
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Old 10-20-2011
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raynauds tx is dihydropyridine Ca blocker ( nifidipine amlodipine etc)
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Ca channel blockers like nifedipine
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C. Calcium-channel blocker, dihydropyridine for Raynaud's phenomenon.
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Old 10-20-2011
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C. Calcium-channel blocker, dihydropyridine
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The correct answer is C. This patient likely has early scleroderma or CREST syndrome, which can initially present as severe Raynaud's phenomena. A host of serologic tests are available to help guide diagnosis, though the sensitivity and specificities of these tests are less than originally thought. In any case, the treatment is mainly supportive. For severe Raynaud syndrome, calcium channel blockers (CCB) can help reduce vasospasm and are often needed only during cold months. The dihydropyridine class has the greatest affinity for peripheral vascular smooth muscle as compared with cardiac calcium channels, and should be used instead of nondihyropyridine CCBs (choice D).

ACE inhibitors (choice A) can be used for renal involvement with systemic sclerosis (and are the treatment of choice for a sclerodermal renal crisis), but will not help this patientís Raynaud phenomena.

Beta-blockers (choice B) can theoretically worsen vasospasm by creating unopposed alpha-receptorĖmediated vasoconstriction. They should be avoided if possible.

Prednisone (choice E) is not helpful for Raynaud's but, if severe connective tissue disease were found to be driving this patientís symptoms, could possibly have a future role in her management.
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