diltiazem hydrochloride

(dil tye' a zem)
Alti-Diltiazem (CAN), Apo-Diltiaz (CAN), Cardizem, Cardizem CD, Cardizem LA, Cardizem SR, Cartia XT, Dilacor XR, Diltia XT, Gen-Diltiazem (CAN), Novo-Diltiazem (CAN), Nu-Diltiaz (CAN), Tiamate, Tiazac Pregnancy Category C
Drug classes

Calcium channel blocker Antianginal Antihypertensive
Therapeutic actions

Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells, resulting in the depression of impulse formation in specialized cardiac pacemaker cells, slowing of the velocity of conduction of the cardiac impulse, depression of myocardial contractility, and dilation of coronary arteries and arterioles and peripheral arterioles; these effects lead to decreased cardiac work, decreased cardiac energy consumption, and in patients with vasospastic (Prinzmetal's) angina, increased delivery of oxygen to myocardial cells.
Indications

• • • •

Angina pectoris due to coronary artery spasm (Prinzmetal's variant angina) Effort-associated angina; chronic stable angina in patients not controlled by betaadrenergic blockers, nitrates Sustained- and extended-release forms: Essential hypertension Parenteral: Paroxysmal supraventricular tachycardia, atrial fibrillation, atrial flutter Allergy to diltiazem, impaired hepatic or renal function, sick sinus syndrome, heart block (second or third degree), lactation.

Contraindications and cautions

Available forms

Tablets—30, 60, 90, 120 mg; ER tablets—180, 240, 300, 360, 420 mg; SR tablets—60, 90, 120 mg; ER capsules—60, 90, 120, 180, 240, 300, 360, 420 mg; injection—5 mg/mL; powder for injection—25, 100 mg
Dosages

Evaluate patient carefully to determine the appropriate dose of this drug.
ADULTS

Initially, 30 mg PO qid before meals and hs; gradually increase dosage at 1- to 2-day intervals to 180–360 mg PO in three to four divided doses.
Sustained and extended release

Cardizem SR: Initially, 60–120 mg PO bid; adjust dosage when maximum antihypertensive effect is achieved (around 14 days); optimum range is 240–360 mg/day.

Cardizem CD and Cartia XT: 180–240 mg daily PO for hypertension; 120–180 mg daily PO for angina. Dilacor XR and Diltia XT: 180–240 mg daily PO as needed; up to 480 mg has been used. Tiazac: 120–240 mg daily PO for hypertension—once daily dose; 120–180 mg PO once daily for angina.
IV

Direct IV bolus: 0.25 mg/kg (20 mg for the average patient); second bolus of 0.35 mg/kg. Continuous IV infusion: 5–10 mg/hr with increases up to 15 mg/hr; may be continued for up to 24 hr.
PEDIATRIC PATIENTS

Safety and efficacy not established.
Pharmacokinetics
Route Oral SR, ER IV Onset 30–60 min 30–60 min Immediate Peak 2–3 hr 6–11 hr 2–3 min

Metabolism: Hepatic; T1/2: 3.5–6 hr; 5–7 hr (SR) Distribution: Crosses placenta; enters breast milk Excretion: Urine
IV facts

Preparation: For continuous infusion, transfer to normal saline, D5W, D5W/0.45% NaCl as below. Mix thoroughly. Use within 24 hr. Keep refrigerated.
Diluent Volume (mL) 100 250 500 Quantity of Injection) 125 mg (25 mL) 250 mg (50 mL) 250 mg (50 mL) Final conc. (mg/mL) 1 — 0.83 — 0.45 — Dose (mg/hr) 10 15 10 15 10 15 Infusion Rate (mL/hr) 10 15 12 18 22 33

Infusion: Administer bolus dose over 2 min. For continuous infusion, rate of 10 mL/hr is the recommended rate. Do not use continuous infusion longer than 24 hr. Incompatibilities: Do not mix in the same solution with furosemide solution.
Adverse effects

• • • •

CNS: Dizziness, light-headedness, headache, asthenia, fatigue CV: Peripheral edema, hypotension, arrhythmias, bradycardia, AV block, asystole Dermatologic: Flushing, rash GI: Nausea, hepatic injury, reflux

Interactions

Drug-drug • Increased serum levels and toxicity of cyclosporine if taken concurrently with diltiazem

Possible depression of myocardial contractility, AV conduction if combined with beta blockers; use caution and monitor patient closely Drug-food • Decreased metabolism and increased risk of toxic effects if taken with grapefruit juice; avoid this combination
Nursing considerations Assessment

• •

History: Allergy to diltiazem, impaired hepatic or renal function, sick sinus syndrome, heart block, lactation, pregnancy Physical: Skin lesions, color, edema; P, BP, baseline ECG, peripheral perfusion, auscultation; R, adventitious sounds; liver evaluation, normal output; liver and renal function tests, urinalysis Monitor patient carefully (BP, cardiac rhythm, and output) while drug is being titrated to therapeutic dose; dosage may be increased more rapidly in hospitalized patients under close supervision. Monitor BP carefully if patient is on concurrent doses of nitrates. Monitor cardiac rhythm regularly during stabilization of dosage and periodically during long-term therapy. Ensure patient swallows ER and SR preparations whole; do not cut, crush, or chew. Swallow SR, ER, and LA preparations whole; do not cut, crush, or chew; do not drink grapefruit juice while using this drug. These side effects may occur: Nausea, vomiting (eat frequent small meals); headache (regulate light, noise, and temperature; medicate if severe). Report irregular heart beat, shortness of breath, swelling of the hands or feet, pronounced dizziness, constipation.

Interventions

• • • •

Teaching points

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Adverse effects in Italic are most common; those in Bold are life-threatening.

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