A 33-year-old Caucasian female presents to your office with a six-month history of cold intolerance. When the weather is cold, her third and fourth fingers on both hands get numb and turn blue. She says, 'I wear gloves to keep my hands warm, but it does not always work'. Her past medical history is significant for non-ulcer dyspepsia treated with omeprazole. She does not smoke or consume alcohol, and denies any recreational drug use. She has no known drug allergies. She works as a nurse at a local hospital and considers her job moderately stressful. She is sexually active with her husband and uses condoms for contraception. Physical examination findings are within normal limits.
Which of the following medications is the best initial treatment for this patient?

Question

A 33-year-old Caucasian female presents to your office with a six-month history of cold intolerance.  When the weather is cold, her third and fourth fingers on both hands get numb and turn blue.  She says, 'I wear gloves to keep my hands warm, but it does not always work'.  Her past medical history is significant for non-ulcer dyspepsia treated with omeprazole.  She does not smoke or consume alcohol, and denies any recreational drug use.  She has no known drug allergies.  She works as a nurse at a local hospital and considers her job moderately stressful.  She is sexually active with her husband and uses condoms for contraception.  Physical examination findings are within normal limits. 
Which of the following medications is the best initial treatment for this patient?

Quizplus · Accepted Answer

Explanation: This patient presents with symptoms suggestive of Raynaud phenomenon, an exaggerated vascular response to cold temperature or emotional stress. Calcium antagonists are considered the first-line pharmacological therapy for these patients, but it should be mentioned that not all calcium antagonists are equally effective. Most dihydropyridine calcium channel blockers (e.g., nifedipine and amlodipine), as well as diltiazem, are proven to work well in these patients. Many other vasodilator agents have been tried to treat this condition. (Choice C)Unlike dihydropyridine calcium channel blockers, verapamil has not been shown to be effective or at least equally effective. (Choice A)Alpha-adrenergic blockers such as prazosin are effective; however, patients eventually become refractory to these agents after prolonged usage. (Choice E)Nitroglycerin is usually used as an adjunct agent to calcium antagonist therapy in patients with severe Raynaud phenomenon. It is not recommended as the first-line agent. (Choice D)Some authors recommend adding aspirin to the treatment regimen in patients with severe ischemia and necrosis to prevent platelet aggregation; however, aspirin should be used with caution because it can actually worsen vasospasm by blocking the synthesis of vasodilatory prostaglandins. Educational Objective: Calcium antagonists, typically nifedipine or amlodipine, are considered the first-line pharmacological therapy for patients with Raynaud phenomenon. References: Calcium-channel blockers for Raynaud's phenomenon in systemic sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/11508437) Rational use of calcium-channel antagonists in Raynaud's phenomenon. (http://www.ncbi.nlm.nih.gov/pubmed/9812220)

A 33-Year-Old Caucasian Female Presents to Your Office with a Six-Month History