Approach to Drug Treatment of Raynaud Phenomenon (RP) and Acute Digital Ischemia - Flowchart
Approach to Drug Treatment of Raynaud Phenomenon (RP) and Acute Digital Ischemia - Flowchart Raynaud Phenomenon Raynaud Phenomenon
«Flowchart»

RP with severe impact on quality of life or with risk for digital ischemia

RP with severe impact on quality of life or with risk for digital ischemia

RP with severe impact on quality of life or with risk for digital ischemia

RP with severe impact on quality of life or with risk for digital ischemia

Yes

Yes

Yes Yes

Persistent severe RP with or without digital ulcers

Persistent severe RP with or without digital ulcers

Persistent severe RP with or without digital ulcers Persistent severe RP with or without digital ulcers

No

No

No No

Lifestyle adjustments; avoid triggers

Lifestyle adjustments; avoid triggers

Lifestyle adjustments; avoid triggers

First line therapy: Start long-active calcium channel blockers (CCB) or PDE5 inhibitors (PDE5i) and non-pharmacological strategies

First line therapy: Start long-active calcium channel blockers (CCB) or PDE5 inhibitors (PDE5i) and non-pharmacological strategies

First line therapy: Start long-active calcium channel blockers (CCB) or PDE5 inhibitors (PDE5i) and non-pharmacological strategies

First line therapy

End

End

End

Second line therapy: Increase CCB to maximum dose; add topical nitrates; consider combination CCB+PDE5i; consider bosentan (if recurrent ulcers); add periodic IV prostacyclin

Second line therapy: Increase CCB to maximum dose; add topical nitrates; consider combination CCB+PDE5i; consider bosentan (if recurrent ulcers); add periodic IV prostacyclin

Second line therapy Second line therapy:

OR

OR

OR OR

Consider local injection of lidocaine or bupivacaine at base of fingers (temporary relief); for acute associated thrombosis consider IV heparin drip (24-72 hours)

Consider local injection of lidocaine or bupivacaine at base of fingers (temporary relief); for acute associated thrombosis consider IV heparin drip (24-72 hours)

Consider local injection of lidocaine or bupivacaine at base of fingers (temporary relief); for acute associated thrombosis consider IV heparin drip (24-72 hours)

Consider surgical consultation for sympathectomy or angioplasty

Consider surgical consultation for sympathectomy or angioplasty

Consider surgical consultation for sympathectomy or angioplasty

Acute or chronic digital ischemia with non-healing ulcers or impending risk for digital loss

Acute or chronic digital ischemia with non-healing ulcers or impending risk for digital loss

Acute or chronic digital ischemia with non-healing ulcers or impending risk for digital loss

Acute or chronic digital ischemia with non-healing ulcers or impending risk for digital loss

Continue CCB (titrated to full tolerated dose) or combination therapy; start antiplatelet therapy (aspirin); start IV prostacyclin

Continue CCB (titrated to full tolerated dose) or combination therapy; start antiplatelet therapy (aspirin); start IV prostacyclin

Continue CCB

No response

No response

No response No response