02/05/2019    Chris Albritton, DPM

Recommendations for Raynaud's Disease

Recently, a podiatry colleague diagnosed an 18-
year-old female with Raynaud’s disease, and asked
for my recommendations for treatment. I sent the
following as a summary of my experience in
treating Raynaud’s disease over the past 38 years
and thought PM News readers might be interested.

First of all, nothing works great in Raynaud's.
Since Raynaud's is a vasospastic problem, I've
had fair success in using alpha-blockers to
counteract vasospasms.

FIRST is prazosin, aka Minipress, starting with 1
mg daily, and increasing to 1 mg qid ... if it
doesn't cause any significant hypotension.
Prazosin is short acting. When I used to go snow
skiing in Colorado, I would take 1 mg prior to
hitting the slopes, and it would help keep my
hands and feet a little warmer due to
vasodilation.

SECOND is terazosin, which is also an alpha-
blocker that is kinda medium in duration of
action. I haven't used it or prescribed it.

THIRD is doxazosin which is longer acting. This
is a fantastic drug, and is available in 1 mg, 2
mg, 4 mg, and 8 mg. It's a very potent
vasodilator, aka Cardura, and is used mostly for
treatment of HTN.

I take doxazosin at 4 mg pO daily and it controls
my HTN well, and creates warmth in my hands such
that patients are pleasantly pleased as my hands
examine their feet (Note also that doxazosin is a
major drug used in the treatment of PBH.).

FOURTH is topical NTG ointment (Nitro-Bid Topical
Ointment 2%). This is a reasonable treatment if
applied topically bid-qid. The downside is cost,
formulary denials, and potential for headaches.

FIFTH is nifedipine, an oral calcium-channel
blocker with more prominent effects on
vasodilation and coronary flow than diltiazem and
verapamil. Works PDG (Pretty Dang Good) in
Raynaud's, but almost always drops patient's BP
to dangerous levels.

So...for initial treatment of a patient with
newly diagnosed Raynaud's, I always recommend
starting with prazosin 1 mg PO daily, and
titrating the dose upwards to a max of 1 mg qid,
according to tolerance. Prazosin is generic and
usually quite inexpensive.

Failing this, I bypass terazosin and go straight
to doxazosin, starting at 2 mg, taking 1/2 tab
daily, and titrating up to 4 mg daily. I've had
on ONE patient who needed 8 mg daily, because he
had painful Marjoli's ulcers of the lower legs,
associated with critical HTN. Doxazosin is
generic, but is more expensive than prazosin.

Next, in the treatment of Raynaud's, I have had
very minimal success with pentoxyphilline,
cilostazol, clopidogrel, and other anti-
coagulants.

Another less effective option for treatment is
reflex vasodilation of the lower extremities by
application of low heat over the abdomen.
One last option is a lumbar sympathetic block by
an anesthesiologist. The downside here is the
pain involved in the block, the short duration of
the block, and the cost of the block compared to
oral medications.

Chris Albritton, DPM, Abilene, TX

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02/07/2019    Paul Clint Jones, DPM

Recommendations for Raynaud's Disease (Chris Albritton, DPM)

I would like to extend kudos to Dr. Albritton.
That was very well outlined and clear as to the
standard of care of treatment for Raynaud’s.
Raynaud’s is undoubtedly difficult to get
consistent results. I commend you. I would like
to point out that this outline clarifies that
these drugs are off-label use and have the common
side effect of orthostatic hypotension. In my
experience, it’s also, difficult to convince an
otherwise healthy patient of any age, to begin
taking an anti-hypertensive drug.

That being said, I would like to share a trick I
stumbled upon in northern Idaho, while treating
diabetic miners with peripheral neuropathy. Like
most doctors, I’ve always tried to begin with the
most benign therapy before employing therapy with
higher risks, i.e. conservative care before
surgery.

Metanx( Metafolin L-Methylfolate Ca , B6, B12) is
a popular treatment for Diabetic Neuropathy.
It’s not a perfect therapy, but certainly holds
it place as a quality treatment of diabetic
neuropathy with minimal risk to the patient. As
my diabetics started using the Metafolin,
several with Raynaud’s, noticed improvement in
their Raynaud’s symptoms. Their Raynaud’s
responded surprisingly fast,without side-effects.

As I looked into it further, Metafolin, as an
activated form of Folic Acid, has no limitation
in the patient age group it could be used on. I
have used it on patients as young as 10 years
old. Worked nicely. Also, for those patients
that are seasonally effected, there was no issues
with starting and stopping its use on an as
needed basis. I don’t know when was the last
time I could do that with a “medication.”
Obviously, there are contraindications for its
its use. It should not be used with patients with
known allergies to its ingredients, history of
seizures, or cancer.

As a primary therapy for Raynaud’s, I first
started with once-daily, Mentanx. Then, as I
refined its use, I switched to its sister
medication Deplin. Deplin is labeled as an
antidepressant, but only contains the active
ingredient, Metafolin. The cost is the same as
Metanx, but it has a higher dose of Metafolin. I
will also, supplement the patient with vitamin
B12 to prevent a secondary development of
pernicious anemia. I must reiterate, this is
simply Methylated Folate, the activated form of
folic acid. And yes, I have seen a negative
difference in using regular Folic Acid or
supposed generics.

In my experience, Metafolin has been as a benign
an approach one can take in treating Raynaud’s
symptoms with surprisingly good results. I would
be interested to hear back about the results
others may be having.

Metafolin is the trade-name for the unique
Metafolin L-Methylfolate Ca formulation found in
Metanx & Deplin and it is patented by Merck
Germany. Because it’s a medical food it is
manufactured under FDA guidelines compared to
other over-the-counter supplements.

Paul Clint Jones, DPM

Disclosure: I have no financial connections with
Metanx, Deplin or their manufacture, Alfasigma
USA, Inc.