A 20-year-old woman comes to the physician because her fingers turn white episodically. The symptoms started 6 months ago during the summer when she noticed that opening the freezer or holding cold beverages precipitated these episodes. She was advised to avoid cold stimuli and wear protective gloves. However, the symptoms worsened during the winter and the episodes occurred more frequently. She feels numbness and pain with each episode and seeks relief.
The patient has no skin thickening, chest pain, acid reflux symptoms, or shortness of breath. She has no other past medical history. She does not smoke but drinks alcohol occasionally.
Her vital signs are within normal limits. The remainder of the physical examination is within normal limits. The hand is shown in the picture.

Laboratory results are as follows:

Which of the following is the most appropriate pharmacotherapy?

Question

A 20-year-old woman comes to the physician because her fingers turn white episodically.  The symptoms started 6 months ago during the summer when she noticed that opening the freezer or holding cold beverages precipitated these episodes.  She was advised to avoid cold stimuli and wear protective gloves.  However, the symptoms worsened during the winter and the episodes occurred more frequently.  She feels numbness and pain with each episode and seeks relief.
The patient has no skin thickening, chest pain, acid reflux symptoms, or shortness of breath.  She has no other past medical history.  She does not smoke but drinks alcohol occasionally.
Her vital signs are within normal limits.  The remainder of the physical examination is within normal limits.  The hand is shown in the picture.

Laboratory results are as follows:

Which of the following is the most appropriate pharmacotherapy?

Quizplus · Accepted Answer

11ec193a_9928_1089_853d_b9598b6e04bc_MD0002_00 This patient's presentation is consistent with likely primary Raynaud's phenomenon (RP), an increased vascular response to cold temperature or emotional stress without an underlying cause. Primary RP usually occurs in women < age 30 with symmetrical episodic attacks without evidence of peripheral vascular disease, tissue injury, or abnormal nailfold capillary examination. Laboratory studies (eg, ANA, ESR) are usually negative. Episodes can also involve tingling, numbness, and pain with skin color changes of pallor (white attack) or cyanotic (blue attack). Primary RP requires no further evaluation. Treatment primarily involves avoiding aggravating factors (eg, cold stimuli) as the risk of tissue-damaging digital ischemia is less likely with primary RP. Calcium channel blockers (eg, nifedipine, amlodipine) are the drugs of choice for continuing symptoms. (Choice B) Aspirin combined with calcium channel blockers may be used in selected patients with severe secondary RP who are at risk for digital ulceration or larger-artery thrombotic events. However, aspirin alone will not alleviate symptoms. (Choices C and D) Hydroxychloroquine and prednisone are used to treat SLE and RA, which can cause secondary RP. However, this patient's lack of systemic findings (eg, fever, joint pain, rash) makes these less likely. (Choice E) Beta-blockers can actually worsen Raynaud's phenomenon and should be avoided in this patient. Educational objective: Primary Raynaud's phenomenon is an increased vascular response to cold temperature or emotional stress. It usually presents in women < age 30 with symmetrical episodic attacks without evidence of peripheral vascular disease, tissue injury, or abnormal nailfold capillary examination. Treatment primarily involves avoiding aggravating factors and calcium channel blockers (eg, nifedipine, amlodipine) in resistant cases. __________ References: Rational use of calcium-channel antagonists in Raynaud's phenomenon. (http://www.ncbi.nlm.nih.gov/pubmed/9812220) Raynaud's phenomenon (primary). (http://www.ncbi.nlm.nih.gov/pubmed/21401971) Management of Raynaud's phenomenon in the patient with connective tissue disease. (http://www.ncbi.nlm.nih.gov/pubmed/20842555)

A 20-Year-Old Woman Comes to the Physician Because Her Fingers