Efficacy of ketanserin in the therapy of Raynaud's phenomenon: thermometric data

Cold-Induced Skin Disorders

Background:

Humans are commonly exposed to extremes in temperature. Fortunately, our skin behaves as an anatomic and physiologic barrier during these periods. Exposure to cold temperatures may result in a variety of symptoms and disorders.

Objective:

Our current understanding of the pathophysiology, clinical presentation, and therapies of cold-induced skin disorders are reviewed.

Methods:

Studies, reviews, and book chapters that contained information on cold-induced skin disorders were reviewed.

Conclusion:

Cold-induced skin disorders are a heterogeneous group of disorders that cause great morbidity, particularly in cold climates. These entities can be classified as physiologic or pathologic responses to freezing or nonfreezing cold exposure.

Oral vasodilators for primary Raynaud's phenomenon

BACKGROUND

Many different drugs have been suggested for the symptomatic treatment of primary Raynaud's phenomenon. Apart from calcium channel blockers, which are considered the drugs of choice, the evidence of the effects of alternative pharmacological treatments is limited. This is an update of a review first published in 2008.

OBJECTIVES

To assess the effects of various drugs with vasodilator actions on primary Raynaud's phenomenon.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched 14 May 2012), CENTRAL (Issue 4, 2012) and clinical trials databases. We contacted one pharmaceutical company and one trial author for additional information. In addition, the reference lists of relevant studies were searched for additional citations. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials evaluating the effects of oral formulations of any drug with vasodilator effects on subjective symptoms in primary Raynaud's phenomenon. Treatment with, or comparison with, calcium channel blockers was not assessed in this review.

DATA COLLECTION AND ANALYSIS

Two members of the review team independently assessed the trials for inclusion and their quality and extracted the data. Data extraction included adverse events. We contacted trial authors for missing data.

MAIN RESULTS

Eight studies involving 290 participants were included. Two trials examined the effects of captopril, the rest were single trials on single drugs. All comparisons were with placebo. The methodological quality of most trials was poor.Enalapril was associated with a small increase in the frequency of attacks per week (difference in means 0.8; 95% CI 0.43 to 1.17). The difference between the intervention groups on a subjective improvement score was non-significant. There was a significant effect of buflomedil on the frequency of attacks per week (weighted mean difference (WMD) -8.8; 95% CI -17.55 to -0.09), but there was no evidence of effect on the severity score. The proportion with fewer attacks was significantly higher on moxisylyte than on placebo (relative risk (RR) 4.33; 95% CI 1.36 to 13.81). For captopril, beraprost, dazoxiben and ketanserin there was no evidence of an effect on the frequency, severity or duration of attacks. Beraprost and moxisylyte gave significantly more adverse effects than placebo.

AUTHORS' CONCLUSIONS

Poor methodological quality, small sample sizes and the limited data available resulted in low precision of the statistical results and limited value of the overall results .The overall results show that there is no evidence for an effect of vasodilator drugs on primary Raynaud's phenomenon.

Central 5-HT receptors in cardiovascular control during stress

Our aim is to consolidate recent data on relationship between central serotonergic neurotransmission and stress-elicited cardiovascular changes. Activation of central of 5-HT1A receptors attenuates tachycardic and pressor changes elicited by a wide range of stressors (airjet, restraint, open field, fear conditioning, social defeat), supporting the previous view of these receptors as "sympathoinhibitory". Their likely location is the medullary raphe. It is still unknown whether 5-TH1A receptors are sympathoinhibitory in physiological condition, as 5-HT1A antagonists do not affect basal or stress-altered cardiovascular parameters. In contrast to the established view that central 5-HT2A receptors are "sympathoexcitatory", experiments with new selective antagonists indicate that these receptors do not mediate stress-induced pressor and tachycardic responses, and are not involved in cardiovascular control at rest. The exception is control of cutaneous vascular bed, both at rest and during stress, likely at the spinal level. 5-HT3 receptors located in the nucleus tractus silitarius (NTS) contribute to stress-induced suppression of the baroreflex. 5-HT3 receptors located in sympathetic ganglia possibly contribute to the development of sustained hypertension in chronically stressed rats.

Oral vasodilators for primary Raynaud's phenomenon

BACKGROUND

Many different drugs have been suggested for the symptomatic treatment of primary Raynaud's phenomenon. Apart from calcium channel blockers, which are considered the drugs of choice, the evidence of the effects of alternative pharmacological treatments is limited.

OBJECTIVES

To assess the effects of various drugs with vasodilator actions on primary Raynaud's phenomenon.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched 24 July 2007), and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 3, 2007). In addition, we searched MEDLINE (January 1966 to July 2007), EMBASE (1980 to July 2007) and reference lists of relevant articles. We contacted pharmaceutical companies. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials evaluating the effects of oral formulations of any drug with vasodilator effects on subjective symptoms in primary Raynaud's phenomenon. Treatment with, or comparison with, calcium channel blockers was not assessed in this review.

DATA COLLECTION AND ANALYSIS

Both authors assessed the trials for inclusion and their quality. One author (BV) extracted the data MS checked the results. Data extraction included adverse events. we contacted trial authors for missing data.

MAIN RESULTS

Eight studies involving 290 participants were included. Two trials examined the effects of captopril, the rest were single trials on single drugs. All comparisons were with placebo. The methodological quality of most trials was poor. Enalapril was associated with a small increase in the frequency of attacks per week (difference in means 0.8; 95% CI 0.43 to 1.17). The difference between the intervention groups on a subjective improvement score was non-significant. There was a significant effect of buflomedil on the frequency of attacks per week (weighted mean difference (WMD) -8.8; 95% CI -17.55 to -0.09), but there was no evidence of effect on the severity score. The proportion with fewer attacks was significantly higher on moxisylyte than on placebo (relative risk (RR) 4.33; 95% CI 1.36 to 13.81). For captopril, beraprost, dazoxiben and ketanserin there was no evidence of an effect on the frequency, severity or duration of attacks. Beraprost and moxisylyte gave significantly more adverse effects than placebo.

AUTHORS' CONCLUSIONS

Poor methodological quality, small sample sizes and the limited data available resulted in low precision of the statistical results and limited value of the overall results . The overall results show that there is no evidence for an effect of vasodilator drugs on primary Raynaud's phenomenon.

Ketanserin for Raynaud's phenomenon in progressive systemic sclerosis

OBJECTIVES

To assess the effects and toxicity of the following agent: ketanserin versus placebo proposed for the treatment of Raynaud's phenomenon (RP) in scleroderma.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register, and Medline up to 1996 using the Cochrane Collaboration search strategy developed by Dickersin et al.(1994). Key words included: Raynaud's or vasospasm, scleroderma or progressive systematic sclerosis or connective tissue disease or autoimmune disease. Current Contents were searched up to and including April 7, 1997. All bibliographies of articles retrieved were searched and key experts in the area were contacted for additional and unpublished data. The initial search strategy included all languages.

SELECTION CRITERIA

All randomized controlled trials comparing ketanserin versus placebo were eligible if they reported clinical outcomes of interest. Trials with dropout rates greater than 35% were excluded.

DATA COLLECTION AND ANALYSIS

Data were abstracted independently by two reviewers (DF, AT). Peto's odds ratios (OR) were calculated for all dichotomous outcomes, and a weighted mean difference (WMD) was carried out on all continuous outcomes. A fixed effects or random effects model were used if the data was homogeneous or heterogeneous, respectively.

MAIN RESULTS

Three trials and 66 patients were included. The proportion improved was significantly better in the group on ketanserin with an odds ratio (OR) of 4.80 (95% CI 1.33, 17.37). However, when comparing ketanserin to placebo, the decrease in severity of RP attacks favoured placebo but this was not statistically significant. Side effects were significantly more common in the group using active treatment with an OR of 5.96 (95% CI 1.61, 22.06). Frequency of attacks did not change, but the duration of attacks decreased significantly in the ketanserin group.

REVIEWER'S CONCLUSIONS

Ketanserin may have some efficacy in the treatment of Raynaud's phenomenon secondary to scleroderma. Overall, ketanserin is not significantly different from placebo for the treatment of Raynaud's phenomenon except for some decrease in the duration of attacks and more subjects improved on ketanserin compared to placebo. However, there were more side effects. It can be concluded that ketanserin treatment in Raynaud's phenomenon secondary to scleroderma is not clinically beneficial.

Serotonin and serotonin antagonism in cardiovascular and non-cardiovascular disease

Serotonin, or 5-hydroxytryptamine, is a naturally-occurring vasoactive substance found primarily in the brain, enterochromaffin tissue, and blood platelets. It has diffuse cardiophysiologic effects. The multiple effects of serotonin on blood vessels can be explained by the existence of 2 serotonergic receptor subtypes (the S1 receptor mediates vasodilation, and the S2 receptor vasoconstriction). Serotonin via the S2 receptor also augments the actions of several other vasoconstricting substances. Serotonin may be responsible for causing, or at least perpetuating, some forms of systemic hypertension through peripheral and central nervous system (CNS) actions. Ketanserin is a highly selective S2-serotonergic antagonist with additional alpha-adrenergic blocking activity, which has been proposed as a therapy for various cardiovascular diseases including hypertension. It has been shown to be more effective than placebo in treating hypertension and comparable in effectiveness to other antihypertensive drugs. Its major side effects relate to the CNS, and prolongation of the electrocardiogram QT interval has been described. Caution must be used when using ketanserin in patients receiving potassium- and magnesium-losing agents, because of the risk of torsades de pointes. Ketanserin has potential utility in the treatment of eclampsia, peripheral vascular disease, carcinoid syndrome, and "shock lung." The drug is not yet approved for clinical use in the United States.

Raynaud's phenomenon in the emergency department

Raynaud's phenomenon manifests as triphasic color changes of the digits, induced by exposure to low temperature or emotional stress. It is a relatively common disorder, estimated to affect 5% to 10% of the general population and 25% to 30% of otherwise healthy women. Although usually self-limiting, it can be severely painful and debilitating, and complicated by ulcerations and tissue necrosis. For the emergency physician treating a patient with an acute presentation of the phenomenon, the main challenges are to achieve adequate pain control, reverse vasospasm, and maintain viable tissue. Emergency treatment can also extend to patient education and arrangement of appropriate referrals and follow-up care.

The efficacy of anti-serotoninergic agents in the treatment of erectile dysfunction

We investigated 3 agents with antiserotoninergic activity (oral trazodone, ketanserin and mianserin) in a double-blind randomized placebo controlled design in terms of the effectiveness in erectile dysfunction. Positive response rates to 30 days of treatment were 65.2% with trazodone, 19.1% with ketanserin, 31.6% with mianserin and 13.6% with placebo. Response to trazodone treatment was significantly better than with placebo (p = 0.0004) and the other 2 agents (p = 0.03 and p = 0.002 for mianserin and ketanserin, respectively). The effectiveness of ketanserin and mianserin seemed to be greater than that of placebo but the differences did not reach statistical significance (p = 0.63 and p = 0.17, respectively).

Cutaneous laser Doppler flowmetry: applications and findings

OBJECTIVE

To examine the historical development, evolution, strengths and weaknesses, and applications (current and future) of laser Doppler flowmetry (LDF).

DESIGN

A review and summary of the literature on the cutaneous uses and successful applications of LDF are presented as well as a brief discussion of the noncutaneous and nonvascular applications.

MATERIAL AND METHODS

LDF measures Doppler-shifted quantities of reflected laser light at a superficial level to determine cutaneous and noncutaneous microcirculatory flux of erythrocytes. LDF is non-invasive and inexpensive.

RESULTS

This relatively recent technologic development has shown considerable potential as a tool for evaluating the cutaneous circulation. Although early studies suggested that LDF had substantial difficulties with sampling, stability, and reproducibility, subsequent refinements in equipment and application have led to technical acceptability.

CONCLUSION

LDF seems to be particularly valuable for assessing the microcirculation and real-time changes in skin blood flow. It has been used successfully in many investigations of the cutaneous and noncutaneous blood flow in patients with fixed or vasospastic vascular disorders, neuropathies, tumors, or ulcers as well as those who have undergone intestinal, orthopedic, or plastic surgical procedures.

Pentoxifylline

Pentoxifylline (oxpentifylline) is a methylxanthine derivative with potent hemorrheologic properties. In the United States it is marketed for the treatment of intermittent claudication. Human and animal studies have shown that pentoxifylline therapy results in a variety of physiological changes at the cellular level, which may be important in treating a diverse group of human afflictions. Immune modulation includes increased leukocyte deformability and chemotaxis, decreased endothelial leukocyte adhesion, decreased neutrophil degranulation and release of superoxides, decreased production of monocyte-derived tumor necrosis factor, decreased leukocyte responsiveness to interleukin 1 and tumor necrosis factor, inhibition of T and B lymphocyte activation, and decreased natural killer cell activity. Hypercoagulable states improve through decreased platelet aggregation and adhesion, increased plasminogen activator, increased plasmin, increased antithrombin III, decreased fibrinogen, decreased alpha 2-antiplasmin, decreased alpha 1-antitrypsin, and decreased alpha 2-macroglobulin. Wound healing and connective tissue disorders may respond to an increase in fibroblast collagenases and decreased collagen, fibronectin, and glycosaminoglycan production. Fibroblast responsiveness to tumor necrosis factor is also diminished. Potential medical uses of pentoxifylline are reviewed.