2.6.2 Calcium-channel blockers (CCBs)

CCBs are divided into two subtypes which have important pharmacological differences:

  1. rate-limiting non-dihydropyridine CCBs – verapamil and diltiazem – which are negatively inotropic and should be avoided in heart failure or reduced left ventricular function
  2. dihydropyridine CCBs – amlodipine, felodipine, lacidipine, lercanidipine, nicardipine, nifedipine and nimodipine

Hypertension

ChoiceDrugDosage
1st choice Amlodipine tablets 5mg, 10mgDose:
initially 5mg once daily, max 10mg once daily
2nd choiceFelodipine tablets m/r
2.5mg, 5mg, 10mg
Dose:
Initially 5mg (elderly 2.5mg) daily in the morning; usual maintenance 5-10mg once daily; doses above 20mg daily rarely needed

Angina

ChoiceDrugDosage
1st choice calcium channel blocker (patient taking a beta-blocker)Amlodipine tablets 5mg, 10mgDose:
Angina, initially 5mg once daily, max 10mg once daily
1st choice calcium channel blocker (in patients unable to tolerate a beta-blocker)

Diltiazem m/r tablets 60mg, 90mg, 120mg; m/r capsules 60mg, 90mg, 120mg, 180mg, 200mg, 240mg, 300mg, 360mg
Prescribe by brand name

Dose:
According to brand
See BNF

Supraventricular arrhythmias – to be used under secondary care guidance only

ChoiceDrugDosage
1st choice

Verapamil m/r tablets 120mg, 240mg; m/r capsules 120mg, 180mg, 240mg
Prescribe by brand name

Dose:
According to brand
See BNF

Prescribing Notes

  • The most common problem with amlodipine is ankle oedema, which may necessitate stopping as the oedema responds poorly to leg elevation or diuretics.
  • A trial of felodipine m/r may be reasonable if a patient develops ankle oedema with amlodipine.
  • The treatment of patients currently receiving concomitant simvastatin 40 mg and amlodipine or diltiazem should be reviewed at their next routine appointment. Switch to atorvastatin 20mg [preferred] (see section 2.12) or reduce simvastatin to 20 mg per day. See Drug Safety Update – Simvastatin:dose limitations with concomitant amlodipine or diltiazem.
  • The rate limiting CCBs diltiazem or verapamil may be considered for angina or following myocardial infarction if a beta-blocker cannot be used.
  • Diltiazem and verapamil have negative inotropic effects and should be avoided in patients with LV dysfunction or heart failure.
  • A long-acting formulation should be used if diltiazem is prescribed. Different versions of modified-release preparations may not have the same clinical effect. To avoid confusion between these different formulations of diltiazem, prescribers must specify the brand to be dispensed.
  • Diltiazem should only be used with secondary care guidance when given with beta-blockers due to risk of bradycardia.
  • Verapamil may be used to treat supraventricular arrhythmias or, occasionally, atrial fibrillation (see section 2.3.2).
  • Verapamil should not be used with beta-blockers as concomitant use can result in extreme bradycardia. It must be avoided in patients with heart block or heart failure.
  • Short-acting dihydropyridines (e.g. standard release nifedipine) may be harmful and these are no longer recommended for angina or hypertension.