What are the recommended first-line treatments for patients with primary Raynaud's phenomenon?

First-line treatment for patients with primary Raynaud's phenomenon involves lifestyle modifications and pharmacological therapy primarily using calcium channel blockers.

Initially, patients should be advised on lifestyle measures such as avoiding cold exposure and sudden temperature changes, keeping the whole body warm with layered clothing and gloves, stopping smoking, reducing caffeine intake, and managing stress, as these can significantly reduce symptom frequency and severity ¹.

If symptoms persist despite these measures, the recommended first-line pharmacological treatment is oral nifedipine, a calcium channel blocker. Immediate-release nifedipine can be started at 5 mg three times daily and titrated up to 20 mg three times daily based on response and tolerability. Alternatively, sustained-release nifedipine, which may have fewer adverse effects, can be initiated at 10 mg twice daily and increased up to 40 mg twice daily ¹.

Should nifedipine be ineffective or not tolerated, amlodipine is considered a suitable alternative, starting at 5 mg once daily and titrating up to 10 mg once daily ¹.

Evidence from a Cochrane systematic review supports the use of calcium channel blockers in reducing the frequency of Raynaud's attacks by approximately six episodes per week compared to placebo, with moderate-quality evidence for reduced severity and some improvement in pain and disability (Rirash et al., 2017). Higher doses may be more effective, and calcium channel blockers appear more beneficial in primary rather than secondary Raynaud's phenomenon (Rirash et al., 2017).

Intermittent use of these medications during cold weather or outdoor winter activities may be sufficient for symptom control in primary Raynaud's phenomenon, and periodic reassessment is advised as remission can occur, potentially obviating the need for long-term treatment ¹.

Overall, the UK guidelines and recent literature converge on calcium channel blockers as the cornerstone of first-line pharmacological management, supported by lifestyle interventions as foundational therapy ¹; (Rirash et al., 2017); (Ramahi et al., 2022).