Author: Chandratre P.N.; Chiu Y.H.; George E.
Abstract: Background RP is described as the vasospasm of arteries or arterioles, usually causing a triphasic colour change. To our knowledge there are no guidelines for prostacyclin use in RP to date. We studied systematic review of 7 randomized trials with variable evidence for the use of prostacyclin in RP, which formed a benchmark for our clinical practice and the basis for our recommendations (Pope, Fenlon et al. 1998) Objectives To develop in-house guidelines to optimise the treatment of RP in terms of cost and clinical
effectiveness. Methods We conducted a retrospective analysis of 21 patients, identified through our departmental Iloprost database. All data was extracted using a pre-developed form from the case notes by two independent reviewers. Clinical governance approval was sought prior to casenote retrieval from the medical records department. Results 52% of the patients had RP secondary to scleroderma. As expected 90% were females. The most frequently reported symptoms were pain (31%) followed by pallor (29%) which led to treatment with iloprost rather than adverse effect on activities of daily living (17%) or ulcers (9%). Nifedipine was the other drug of choice (35%) followed by others such as fluoxetine and ACE inhibitors. The side effect profile was similar across all of the drugs used. The follow up time was greater than 10 weeks for 67% of the patients. Previous iloprost use was documented in 24% of the patients with only 60% of those reporting benefit. The medication charge was 479.40 for a 5 day course of iloprost (excluding
staffing and day case admission). We found no evidence of documentation of the number, site and severity of attacks of RP prior to iloprost infusion Conclusions Our recommendations would be to document specific indications such as frequency, site and severity of attacks as well as improvement post infusion through a standardized RP assessment proforma. It is also important to assess impact of RP on activities of daily living and quality of life (inclusion of HAQ-DI and SF36 sub-scales in the assessment proforma for example). Patient diary maintained 2 week pre and post infusion with visual analogue scales for pain and severity and physician global assessment may be also be useful. Only those patients who have failed on 2 consecutive or combination drugs with a frequency of attacks >5 per week for 2 weeks, severity grade >3 or evidence of ulcers should be eligible for a prostacyclin infusion (Wigley, Wise et al. 1994). Non responders (assessed through patient and physician global VAS) should not be offered repeat prostacyclin infusion. A simple proforma to assess eligibility criteria and response afterwards has been designed for initiation into clinical practice, which needs to be re-audited to close the loop.
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