CCBs are divided into two subtypes which have important pharmacological differences:
- rate-limiting non-dihydropyridine CCBs – verapamil and diltiazem – which are negatively inotropic and should be avoided in heart failure or reduced left ventricular function
- dihydropyridine CCBs – amlodipine, felodipine, lacidipine, lercanidipine, nicardipine, nifedipine and nimodipine
Hypertension
Choice Drug Dosage 1st choice Amlodipine tablets 5mg, 10mg Dose:
initially 5mg once daily, max 10mg once daily 2nd choice Lercanidipine tablets 10mg, 20mg Dose:
Initially 10mg once daily; increased if necessary to 20mg daily
| Choice | Drug | Dosage |
|---|---|---|
| 1st choice | Amlodipine tablets 5mg, 10mg | Dose: initially 5mg once daily, max 10mg once daily |
| 2nd choice | Lercanidipine tablets 10mg, 20mg | Dose: Initially 10mg once daily; increased if necessary to 20mg daily |
Angina
Choice Drug Dosage 1st choice calcium channel blocker (patient taking a beta-blocker) Amlodipine tablets 5mg, 10mg Dose:
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
| Choice | Drug | Dosage |
|---|---|---|
| 1st choice calcium channel blocker (patient taking a beta-blocker) | Amlodipine tablets 5mg, 10mg | Dose: 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
Choice Drug Dosage 1st choice Verapamil m/r tablets 120mg, 240mg
Prescribe by brand name*
Dose:
According to brand
See BNF
| Choice | Drug | Dosage |
|---|---|---|
| 1st choice | Verapamil m/r tablets 120mg, 240mg Prescribe by brand name* | Dose: According to brand See BNF |
*patients switched between brands due to medicines shortages may require closer monitoring of BP in the initial stages
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 lercandipine may be reasonable if a patient develops ankle oedema with amlodipine.
- Felodipine m/r is still a reasonable choice and there is no need to switch patients already stable on felodipine m/r
- 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 MHRA and 2.12 lipid regulating drugs.
- 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.