Review Question - QID 109885

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Scleroderma Treatment Medical QID: 109885 (M1.MK.18.4872)

QID 109885 (Type "109885" in App Search)

A 31-year-old African American woman presents to her primary care provider complaining of stiff, painful fingers. She reports that her symptoms started 2 years ago and have gradually worsened. Her pain is not relieved by ibuprofen or acetaminophen. She is most concerned about having occasional episodes in which her fingers become extremely painful and turn white then pale blue. Her past medical history is notable for hypertension but she has previously refused to take any medication. She works as a postal worker and spends most of her time outside. Physical examination reveals induration of her digits with loss of skin fold wrinkles. She has limited finger range of motion. She would like to know if she can do anything to address her intermittent finger pain as it is affecting her ability to work outside in the cold. Which of the following medications is most appropriate to address this patient’s concerns?

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Ambrisentan

6/218

Diltiazem

9/218

Enalapril

8/218

Methotrexate

43%

94/218

Nifedipine

36%

79/218

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The patient in this vignette presents with finger induration, stiffness, and color change suggestive of scleroderma with associated Raynaud phenomenon. The first-line medical treatment for Raynaud phenomenon is a calcium channel blocker (CCB), frequently dihydropyridine CCBs such as nifedipine.

Scleroderma is an autoimmune condition characterized by hardening and induration of the skin and/or other organs due to collagen deposition and fibrosis. Some patients with scleroderma may experience Raynaud phenomenon in which decreased blood flow to the skin from either cold temperature or stress causes vasospasms. Clinically, this presents as color change in the affected areas from white (ischemia) to blue (hypoxia) to red (reperfusion). Dihydropyridine CCBs such as nifedipine and amlodipine can be used to treat Raynaud phenomenon because these selectively reduce vascular tone.

Incorrect Answers:
Answer 1: Ambrisentan is an endothelin receptor antagonist that is used in combination with tadalafil (phosphodiesterase type 5 inhibitor) to treat pulmonary hypertension in patients with scleroderma.

Answer 2: Diltiazem is a non-dihydropyridine CCB. Since non-dihydropyridine CCBs are less selective for peripheral arteries than dihydropyridine CCBs, they are not commonly used to treat Raynaud phenomenon.

Answer 3: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that can be used to treat hypertension including in scleroderma patients who have hypertension due to renal involvement. Although this patient would likely benefit from an ACE inhibitor, these medications are not used to specifically treat Raynaud phenomenon.

Answer 4: Methotrexate is an immunosuppressive agent that is one of the first-line treatments to prevent the progression of scleroderma. Although this patient would likely benefit from an immunosuppressive agent, methotrexate is not used to specifically treat Raynaud phenomenon.

Bullet Summary:
Dihydropyridine calcium channel blockers such as nifedipine or amlodipine can be used to treat Raynaud phenomenon in patients with scleroderma.

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