How to choose CCB for your patient

hink of dihydropyridine CCBs (amlodipine, nifedipine, etc) as more potent vasodilators, but they can bump up heart rate.....
Abdelwahab Ward, BS Pharm, PharmD

Overview

As a clinical pharmacist, there’s often confusion about how to choose a calcium channel blocker (CCB) due to the laundry list of products and uses. Think of dihydropyridine CCBs (amlodipine, nifedipine, etc) as more potent vasodilators, but they can bump up heart rate. NONdihydropyridines (diltiazem, verapamil) slow heart rate.

Approach

Preferred choices

Preferred choices. Rely on amlodipine (Norvasc, Amlor) as your workhorse CCB for hypertension. It’s the longest-acting dihydropyridine, causes less tachycardia and has more data for improving CV outcomes in hypertension. But think of nifedipine ER (Epilat Retard) as the CCB of choice for hypertension in pregnancy, based on its long safety record.

Lean toward diltiazem instead of verapamil if a CCB is needed for heart rate control, such as with atrial fibrillation. Diltiazem seems to cause less constipation than verapamil. Be aware, most CCBs reduce contractility and should generally be avoided in heart failure with reduced ejection fraction. If a CCB is needed for another reason after optimizing core HF medications, consider amlodipine, it doesn’t significantly reduce contractility. It’s okay to combine a dihydropyridine and NONdihydropyridine. But save this for rare cases when options are limited, such as chronic kidney disease with resistant hypertension.

Side effects and interactions

Dihydropyridines cause more peripheral edema than NONdihydropyridines, due to greater vasodilation. But don’t jump to a diuretic for CCB-induced edema, which is due to fluid “leaking” out of blood vessels, not sodium or water retention.

Try reducing the CCB dose if possible. Or consider adding an ACEI or ARB if additional BP lowering is needed, this might counteract edema. Generally avoid combining diltiazem or verapamil with a beta-blocker, due to risk of bradycardia or heart block. Manage CYP3A4 interactions. For example, reduce colchicine or simvastatin doses with diltiazem or verapamil or consider alternatives.

Formulations

Check products closely when selecting CCBs on the e-Rx pick list to prevent mix-ups. For example, many long-acting forms of diltiazem (Cardizem CD, etc) have different release mechanisms, may be dosed differently and often aren’t automatically substitutable.

References

  1. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018 Sep 1;39(33):3021-3104.
  2. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;71(6):1269-1324.
  3. Heidenreich PA, Bozkurt B, Aguilar D, Aet al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-e1032.
  4. Makani H, Bangalore S, Romero J, et al. Effect of renin-angiotensin system blockade on calcium channel blocker-associated peripheral edema. Am J Med. 2011 Feb;124(2):128-35.
Abdelwahab Ward, BS Pharm, PharmD