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 daily)

Indications

Dose

  • Initially 5mg once daily; maximum 10mg once daily
Diltiazem hydrochloride (standard formulation)

Indication

Notes

  1. Standard formulations containing 60 mg diltiazem hydrochloride are licensed as generics and there is no requirement for brand name dispensing for clinical reasons. Although their means of formulation has called for the strict designation 'modified-release', their duration of action corresponds to that of tablets requiring administration more frequently
  2. Different versions of modified-release preparations containing more than 60 mg diltiazem hydrochloride may not have the same clinical effect. To avoid confusion between these different formulations of diltiazem, prescribers should specify the brand to be dispensed (see entry below).
  3. The combination of diltiazem with beta-blockers should be used with caution.
  4. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)
Diltiazem hydrochloride modified release
  • Adizem-SR® modified release capsules 90mg, 120mg, 180mg (£9.45 = 120mg twice daily)
  • Adizem-XL® modified release capsules 120mg, 180mg, 200mg, 240mg, 300mg (£9.14 = 300mg once daily)
  • Zemtard XL® modified release capsules 120mg, 180mg, 240mg, 300mg (£6.70 = 300mg once daily)

Indications and dose

  • Mild to moderate hypertension
    • Adizem-SR: 120 mg twice daily, dose form not appropriate for initial dose titration
    • Adizem-XL: Initially 240 mg once daily, increased if necessary to 300 mg once daily. Elderly and those with impaired hepatic or renal function, initially 120mg once daily
    • Zemtard XL: Initially 180mg-300mg once daily, increased if necessary to 360mg once daily. Elderly and those with renal impairment, initially 120mg once daily, increased if necessary to 360mg once daily
  • Angina
    • Adizem-SR: Initially 90 mg twice daily; increased if necessary to 180 mg twice daily, dose form not appropriate for initial dose titration in the elderly
    • Adizem-XL: Initially 240 mg once daily, increased if necessary to 300 mg once daily. Elderly and those with impaired hepatic or renal function, initially 120mg once daily
    • Zemtard XL: Initially 180mg-300mg once daily, increased if necessary to 480mg once daily. Elderly and those with renal impairment, initially 120mg once daily, increased if necessary to 480mg once daily

Notes

  1. Prescribe by brand. Different versions of modified-release preparations containing more than 60 mg diltiazem hydrochloride may not have the same clinical effect. Switching patients stabilised on one brand is not routinely recommended. To avoid confusion between these different formulations of diltiazem, prescribers should specify the brand to be dispensed
  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. Standard formulations containing 60 mg diltiazem hydrochloride are licensed as generics and there is no requirement for brand name dispensing for clinical reasons. Although their means of formulation has called for the strict designation 'modified-release', their duration of action corresponds to that of tablets requiring administration more frequently (see individual entry above)
  4. The combination of diltiazem with beta-blockers should be used with caution.
  5. Zemtard XL is the preferred option for patients who have previously been prescribed Slozem capsules (discontinued)
Felodipine
  • Modified release tablets 2.5mg, 5mg, 10mg (£4.21 = 5mg daily)

Indication

Dose

  • Hypertension, initially 5mg (elderly 2.5mg) daily in the morning; usual maintenance 5–10mg once daily; doses above 20mg daily rarely needed
  • Angina, initially 5mg daily in the morning, increased if necessary to 10mg once daily
Lercanidipine
  • Tablets 10mg, 20mg (£3.41 = 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 (£4.80 = 120mg three times a day)
  • Half Securon SR® 120mg (£7.71 = 28 x 120mg)
  • Securon SR® Modified release tablets 240mg (£5.55 = 28 x 240mg)

Indications

  • Supraventricular arrhythmias
  • Angina
  • Hypertension
  • Prophylaxis after myocardial infarction where beta-blockers not appropriate

Dose

  • Supraventricular arrhythmias, 40–120mg 3 times daily
  • Angina, 80–120mg 3 times daily
    • Sustained release: 240 mg twice daily (may sometimes be reduced to once daily)
  • Hypertension, 240–480mg daily in 2–3 divided doses
    • Sustained release: 240mg daily (new patients initially 120mg), increased if necessary to maximum 480mg daily (doses above 240mg daily as 2 divided doses)
  • Prophylaxis after myocardial infarction where beta-blockers not appropriate (started at least 1 week after infarction)
    • Sustained release: 360mg daily in divided doses, given as 240mg in the morning and 120mg in the evening or 120mg 3 times daily

Notes

  1. Please specify the brand when prescribing modified release verapamil to ensure that the patient receives the same modified release preparation. Where a patient already receives a modified release verapamil preparation the existing brand should be prescribed.
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.
    1. 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.
    2. 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.
    3. Licensed indications and recommended dosing frequencies vary between products and should be checked when switching treatments.
    4. Local specialists have provided guidance on switching patients to an alternative calcium-channel blocker which can be found on the Medicines Optimisation Post Live
    5. Further guidance may also be sought from the Specialist Pharmacy Service (SPS)
  2. 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
    1. Further guidance may also be sought from the Specialist Pharmacy Service (SPS)
Nimodipine
  • Tablets 30mg
  • Infusion 200 micrograms/ml

Indications

  • Nimodipine is included for the prevention and treatment of ischaemic neurological deficits following subarachnoid haemorrhage. The full course will be supplied by Secondary Care.

 

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