Losartan therapy for Raynaud's phenomenon and scleroderma: Clinical and biochemical findings in a fifteen-week, randomized, parallel-group, controlled trial

Abstract

Objective. To compare the efficacy and tolerability of losartan, an antagonist of angiotensin II receptor type 1, with nifedipine for the treatment of primary and secondary Raynaud's phenomenon (RP) in a pilot study.Methods. In a randomized, parallel-group, controlled trial, patients with primary RP (n ‫؍‬ 25) or RP secondary to systemic sclerosis (SSc [scleroderma]; n ‫؍‬ 27) were allocated to receive 12 weeks' treatment with either losartan (50 mg/day) or nifedipine (40 mg/day). Primary outcome variables were the severity and frequency of RP episodes and findings on vascular measurements, including thermography and laser Doppler flowmetry. Serum levels of soluble adhesion molecules, endothelin 1, fibrinogen, von Willebrand factor, and procollagen type I N-terminal propeptide (PINP) were also measured.Results. There was a reduction in the severity of RP episodes following treatment with losartan and with nifedipine, but this effect was greater in the losartan arm of the study (P < 0.05): episode frequency was reduced only in the losartan group (P < 0.01 versus baseline). Symptomatic improvement was associated with a significant reduction in soluble vascular cell adhesion molecule 1 and PINP (P < 0.01). Subgroup analysis suggested that although these biochemical changes occurred mainly in SSc patients, the clinical benefit was greater in the primary RP group.Conclusion. This study confirms the tolerability of short-term treatment of RP with losartan, and our data suggest its clinical benefit. Further evaluation of this drug as a long-term treatment for SSc-associated RP should be considered, since it may have additional disease-modifying potential.Episodic digital ischemia provoked by cold and emotion was first described by Maurice Raynaud over 130 years ago (1). When it occurs in isolation, it is designated primary Raynaud's phenomenon (RP) to distinguish it from those cases in which there is an underlying or associated pathology. It affects ϳ10% of the adult population, with a predilection for females, and up to 5% of patients presenting with this condition later develop an autoimmune rheumatic disorder, such as systemic sclerosis (SSc; scleroderma) (2). Successful treatment is often difficult, and although clinical trials suggest that vasodilators can be effective, the responses of individual patients to a particular agent are often idiosyncratic.The pathogenesis of the vascular dysfunction underlying RP is incompletely understood, and relatively few well-controlled clinical trials with vasoactive drugs have been undertaken. Lack of distinction between primary and secondary RP in some of these studies makes their interpretation difficult. Calcium channel antagonists such as nifedipine have been shown to be effective (3-6), although striking differences in individual responses have been described (3,7). Moreover, efficacy is often particularly limited in patients with RP

To compare the efficacy and safety of nifedipine sustained release with Ginkgo biloba extract to treat patients with primary Raynaud’s phenomenon in South Korea; Korean Raynaud study (KOARA study)

“…Although some clinical trials on patients with primary or secondary RP using nifedipine have been performed intermittently [16][17][18][19], this study was the first clinical trial using South Korean patients with primary RP as its subjects.…”

ESVM guidelines – the diagnosis and management of Raynaud’s phenomenon

“…Other medical therapies [37]: Endothelin-1 receptor antagonists also have been investigated. Bosentan has been evaluated as a treatment of digital ulceration secondary to SSc and conferred benefi t in two multicentre RCTs [38,39] in terms of prevention of new ulcers, although it had no effect on healing of existing ulcers.…”

Raynaud’s phenomenon and digital ischaemia - pharmacologic approach and alternative treatment options

“…Twenty-fi ve patients with primary RP and 27 patients with secondary RP were allocated to receive either losartan 50 mg or sustained-release nifedipine 40 mg per day, and were followed for 12 weeks [38]. Losartan caused a signifi cant reduction in the frequency and severity of RP episodes (49 %; p = 0.003 and 50 %; p = 0.009, respectively), while nifedipine resulted in only an 18 % reduction in severity (p = 0.49).…”

“…With regard to vasculitis, secondary RP occurs more frequently in thrombangiitis obliterans (Buerger's disease) and in small and medium-sized vessel vasculitis than in largevessel vasculitis [ESM 2,[36][37][38][39][40], and it often predicts a more progressive course of the disease. In particular, patients with secondary RP related to connective tissue diseases (CTD) are at high risk for developing digital skin ulcers.…”