2.6.2 Calcium-channel blockers

There are important differences between dihydropyridines and other classes of calcium channel blockers.

Avoid the combination of verapamil with a beta-blocker (including eye drops). The combination of diltiazem with beta-blockers should be used with caution.

Avoid verapamil and diltiazem in heart failure.

Amlodipine
  • Tablets 5mg, 10mg (£0.83 = 5mg)

Indications

Dose

  • Initially 5mg once daily; maximum 10mg once daily

Notes

  1. Patients experiencing ankle oedema whilst taking amlodipine may benefit from a change to lercanidipine.
Diltiazem hydrochloride
  • Tildiem® modified release tablets 60mg (£42.93 = 60mg three times daily)
  • Adizem-XL® modified release capsules 120mg, 180mg, 200mg, 240mg, 300mg (£9.14 = 300mg once daily)
  • Tildiem LA® modified release capsules 200mg, 300mg (£6.29 = 200mg once daily)

Indication

Notes

  1. There are pharmacokinetic differences between diltiazem brands, and switching patients stabilised on one brand is not routinely recommended.
    1. Slozem capsules have been discontinued with immediate effect, stocks are expected to be exhausted by the end of February 2020. UKMi have advised prescribers to switch patients to equivalent strength diltiazem preparations.
  2. If diltiazem prescriptions have been written generically in the past, the prescriber should attempt to ascertain which brand the patient has been taking and amend the prescription accordingly. If the brand taken has constantly changed, the prescriber should choose a formulary brand and prepare to review the patient and titrate the dose as appropriate.
  3. The combination of diltiazem with beta-blockers should be used with caution.
Lercanidipine
  • Tablets 10mg, 20mg (£2.40 = 10mg daily)

Indication

Dose

  • Initially 10mg once daily; increased, if necessary, after at least 2 weeks to 20mg daily
Verapamil
  • Tablets 40mg, 80mg, 120mg, 160mg (£13.29 = 120mg three times daily)
  • Half Securon SR® modified release tablets 120mg (£7.71 = 120mg daily)
  • Securon SR® modified release tablets 240mg (£5.55 = 240mg daily)

Indications

  • Arrhythmias
  • Angina
  • Prophylaxis after myocardial infarction where beta-blockers not appropriate

Notes

  1. Avoid the combination of verapamil with a beta-blocker (including eye drops).
  2. Avoid verapamil and diltiazem in heart failure.
Nifedipine (modified-release formulations)
  • Capsules 10mg, 20mg, 30mg, 60mg
  • Tablets 10mg, 20mg, 30mg, 60mg

Indications

Notes

  1. At the time of writing (July 2019) Adalat Retard formulations have been discontinued, and there are long term supply problems with Adalat LA. Other brands remain available including Coracten SR capsules and XL capsules; and Adipine MR tablets and XL tablets however intermittent supply problems with alternative brands have also been observed.
  2. It is advised that modified-release preparations of nifedipine should be prescribed by brand as different preparations may not have the same clinical effect; this may not be possible in the event of supply problems.
  3. When switching between brands closer monitoring of blood pressure may be required in the initial stages and patients reassured that they are receiving the same drug and dose but to report any adverse effects.
  4. Licensed indications and recommended dosing frequencies vary between products and should be checked when switching treatments.
  5. Local specialists have provided guidance on switching patients to an alternative calcium-channel blocker which can be found on the Medicines Optimisation Post Live
  6. Further guidance may also be sought from the Specialist Pharmacy Service (SPS)
  7. Pregnancy: May inhibit labour; manufacturer advises avoid before week 20, but risk to foetus should be balanced against risk of uncontrolled maternal hypertension
Nifedipine (short-acting formulation)
  • Capsules 5mg, 10mg

Indications

  • Raynaud's phenomenon

Dose

  • Initially 5mg 3 times a day, adjusted according to response to 20mg 3 times a day

Notes

  1. The short-acting nifedipine capsules are not to be prescribed for hypertension or angina; their use maybe associated with large variations in blood pressure and reflex tachycardia.
  2. General measures, e.g. withdrawal of beta-blockers, stopping smoking, use of hand warmers, should be encouraged before introduction of drug therapy for Raynaud's phenomenon.
  3. Local specialists have provided guidance on switching patients to an alternative calcium-channel blocker in the event of supply shortages which can be found on the Medicines Optimisation Post Live
  4. Further guidance may also be sought from the Specialist Pharmacy Service (SPS)
Nimodipine
  • Tablets 30mg
  • Intravenous infusion 200 micrograms/ml

Indications

  • Prevention and treatment of ischaemic neurological deficits following aneurysmal subarachnoid haemorrhage

 

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