Comparison of Calcium Channel Blockers
Full update November 2022
Calcium channel blockers (CCBs) are divided into two classes: the non-dihydropyridines (diltiazem [e.g., Cardizem] and verapamil [e.g., Calan]) and the dihydropyridines (all CCBs except verapamil and diltiazem). The terminology used, especially for long-acting products (e.g., ER, CD, CR, XL), is not standardized and can create confusion when trying to determine which products can be substituted for one another. In the US, pharmacists can consult to FDA’s Orange Book for help identifying therapeutic equivalence.
Drug |
Indication and ADULT Doseb |
Comments/Clinical Pearlsb |
DIHYDROPYRIDINES: Mechanism of action involves coronary and peripheral arteriolar vasodilation.1 This can lead to reflex tachycardia, headache, flushing, and peripheral edema.1 The dihydropyridines can impair myocardial contractility to varying degreess.1 Dihydropyridines are CYP3A4 substrates.2 |
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Once-a-day (24 hour) Dihydropyridines |
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Amlodipine (Norvasc, generics); also see footnote a |
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Levamlodipine (Conjupri) (US) |
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Felodipine ER (Plendil [brand discontinued in US], generics) |
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Nifedipine ER (Adalat XL [Canada], Adalat CC [US; brand discontinued], generics [US Orange Book code AB1]) |
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Nifedipine ER (Procardia XL [US], generics [US orange Book code AB2]) |
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Nisoldipine ER (Sular [US], generics) |
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Twice Daily Dihydropyridines |
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Isradipine (DynaCirc [US; brand discontinued], generics) |
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Three Times Daily Dihydropyridines |
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Nicardipine (Cardene [US; brand discontinued], generics) |
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Nifedipine IR (Procardia [US],Adalat [Canada; brand discontinued], generics) |
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NON-DIHYDROPYRIDINES: Compared to dihydropyridines, non-dihydropyridines provide relatively less peripheral and coronary arteriolar vasodilation.1 They have significant negative inotropic and chronotropic effects, with verapamil having the most pronounced effect.3 Use with beta-blockers should be avoided.2 Verapamil and diltiazem are among the first-line options for rate control in A-fib.5 Diltiazem and verapamil are CYP3A4 substrates and inhibitors.2 Constipation is common with verapamil.1 |
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Once-a-Day Non-Dihydropyridines |
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Diltiazem ER (Cardizem CD [US; brand discontinued in Canada], generics [US Orange Book code AB3]) |
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Diltiazem ER (Cardizem LA [US], generic) |
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Diltiazem ER (Dilacor XR [US; brand discontinued], generics [Orange Book code AB2]) |
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Diltiazem ER (Tiazac, generics [US Orange Book code AB4]) |
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Diltiazem ER (Tiazac XC [Canada]) |
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Verapamil ER (Verelan [US], generic available) |
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Verapamil ER (Verelan PM [US]) |
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Verapamil ER/Trandolapril (Tarka [US; brand discontinued]; generic |
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Once to Twice-a-Day (12 hour) Non-Dihydropyridines |
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Diltiazem ER (Cardizem SR [US; brand discontinued], generics [Orange Book code AB1]) |
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Verapamil ER (Calan SR [US], Isoptin SR [Canada], generics) |
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Three and Four Times Daily Non-Dihydropyridines |
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Diltiazem IR (Cardizem [brand discontinued in Canada], generics) |
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Verapamil IR (Isoptin [brand discontinued], generics) |
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Acute Care Calcium Channel Blockers |
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Clevidipine (Cleviprex [US]) |
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Diltiazem injection (Cardizem [brand discontinued], generics) |
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Nicardipine injection (Cardene [US], generics) |
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Nimodipine (Nimotop [brand discontinued in US], generics) |
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Nimodipine (Nymalize [US]) |
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Verapamil injection |
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- Amlodipine combination products: Azor (US; amlodipine/olmesartan; generics), Caduet (amlodipine/atorvastatin; generics), Exforge (US; amlodipine/valsartan; generics), Exforge HCT (US; amlodipine/valsartan/hydrochlorothiazide; generics), Lotrel (US; amlodipine/benazepril; generics), Prestalia (US; amlodipine/perindopril), Tribenzor (US; amlodipine/olmesartan/hydrochlorothiazide; generics), Twynsta (amlodipine/telmisartan [brand discontinued in US]; generics), Viacoram (Canada; atorvastatin/perindopril; generics)
- From US and Canadian product labeling unless otherwise noted.
- US prescribing information used in the creation of this chart: Norvasc (January 2019); Conjupri (December 2019);felodipine ER (Torrent, July 2022); nifedipine extended-release (Aurobindo, June 2021); Procardia XL (May 2021); Sular (July2017); isradipine capsules (Epic, March 2021); nicardipine capsules (ANI, June 2021); Procardia (July 2016); Cardizem CD (April 2020); Cardizem LA (May 2019); diltiazem extended-release capsule (Apotex, July 2012); Tiazac (October 2020); Verelan (October 2019); Verelan PM (October 2019); verapamil ER/trandolapril (Glenmark, September 2019); diltiazem ER capsules (Mylan, November 2020); Calan SR (January 2022); Cardizem (June 2020); verapamil (Heritage, October 2021); Cleviprex (September 2022); Diltiazem injection (Hospira, December 2017); Cardene injection (March 2022); Nimodipine capsules (Bionpharma, November 2017); Nymalize (December 2019); verapamil injection (Exela, September 2021).
- Canadian product monographs used in the creation of this chart: Norvasc (May 2020); Plendil (January 2015); Adalat XL (July 2016); Nifedipine IR capsule (AA Pharma Inc., June 2010); diltiazem CD (Sanis Health, January 2022); Tiazac (June 2021); Tiazac XC (June 2021); Isoptin SR (December 2021); Apo-diltiaz (April 2020); Apo-verap (May 2022); diltiazem injection (Omega Laboratories, March 2021); Nimotop (November 2011), verapamil hydrochloride injection (Sandoz Canada, July 2022).
Abbreviations: ACS = acute coronary syndrome; A-fib = atrial fibrillation; A flutter = atrial flutter; BID = twice daily; BP = blood pressure; CAD = coronary artery disease; CYP = cytochrome P450; ER = extended release; HFrEF = heart failure with reduced ejection fraction; HS = at bedtime; HTN = hypertension; IR = immediate release; MI = myocardial infarction; min = minutes; NG = nasogastric; QD = once daily; Q12 = every twelve; Q4 = every four; Q8 = every eight; QID = four times daily; SVT = supraventricular tachycardia; TID = three times daily.
References
- Cheng JW. Essential hypertension. In: Zeind CS, Carvalho MG, Eds. Applied Therapeutics: the Clinical Use of Drugs. 11th ed. Philadelphia, PA: Wolters Kluwer Health, 2018: 132-61.
- Clinical Pharmacology powered by Clinical Key. Tampa, FL: Elsevier; 2022. http://www.clinicalkey.com. (Accessed October 4, 2022).
- Elliott WJ, Ram CV. Calcium channel blockers. J Clin Hypertens (Greenwich). 2011 Sep;13(9):687-9.
- Briggs GG, Towers CV, Forinash AB. Drugs in Pregnancy and Lactation. 12th ed. Philadelphia, PA: Wolters Kluwer, 2021 (online version accessed October 12, 2022).
- January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014 Dec 2;130(23):e199-267. Erratum in: Circulation. 2014 Dec 2;130(23):e272-4.
Cite this document as follows: Clinical Resource, Comparison of Calcium Channel Blockers. Pharmacist’s Letter/Prescriber’s Letter. November 2022. [381108]
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