III. Precautions

  1. Write for generic Diltiazem ER to allow pharmacist to substitute between multiple similar ER preparations
    1. (2016) Presc Lett 23(7): 39-40

IV. Mechanism

  1. AV Node effects
    1. Slow AV Node Conduction
    2. Prolong AV Node refractory period
  2. Less negative hemodynamic effects than Verapamil
    1. Potent negative chronotropic effect
    2. Minimal negative inotropic effect
    3. Diltiazem effects Left Ventricular Dysfunction less
  3. Coronary vasodilatation

V. Pharmacokinetics

  1. Onset in 2-7 minutes after IV infusion

VI. Contraindications

  1. Wolff-Parkinson-White Syndrome with Atrial Fibrillation
    1. Paroxysmal accelerated ventricular response
    2. Risk of progression into Ventricular Fibrillation
  2. Wide Complex Tachycardia (unless supraventricular)
    1. Risk of severe Hypotension
    2. May progress into Ventricular Fibrillation
  3. Sinus Node or AV Node dysfunction without Pacemaker
    1. AV Block
    2. Sick Sinus Syndrome
  4. Severe Congestive Heart Failure
  5. Concurrent Intravenous Beta Blocker use

VII. Indications

  1. Atrial Fibrillation with rapid ventricular response
    1. Highly effective at controlling ventricular rate
  2. Paroxysmal Supraventricular Tachycardia
    1. Less studied than Verapamil for PSVT
  3. Supraventricular Tachycardia
    1. Terminates AV Node reentry Tachycardias
  4. Hypertension

VIII. Dosing: Rapid Atrial Fibrillation or PSVT

  1. Regimen 1: One Bolus and then maintenance
    1. Bolus: 0.25 mg/kg (to 20 mg) IV over 2 minutes
    2. Maintenance: 10 mg/hour titrated to Heart Rate (typically 5-15 mg/hour)
    3. Mnemonic: Rule of 15 for patient weight of 70 kg
      1. First: 15 mg IV over 2 minutes, then infusion at 15 mg/hour
  2. Regimen 2: Two boluses and then maintenance
    1. Bolus One: 0.25 mg/kg (to 20 mg) IV over 2 minutes
    2. Bolus Two: 0.35 mg/kg (to 25 mg) IV over 2 minutes starting 15 minutes after first bolus
    3. Maintenance: 10 mg/hour titrated to Heart Rate (typically 5-15 mg/hour)
  3. Regimen 3: Hypotensive patient
    1. "Bolus": 2.5 mg/min over 10-20 min infusion
      1. http://ehced.org/wp-content/site/Drips/dilt-load.pdf
    2. Maintenance: 5 mg/hour titrated as Blood Pressure allows to Heart Rate (typically 5-15 mg/hour)
    3. Pretreating with calcium is unlikely to benefit Blood Pressure
      1. At best may offer transient Blood Pressure increase for 10 minutes (secondary to Catecholamine surge)
      2. Calcium infusion could be considered in Hypocalcemia (e.g. Calcium Chloride 0.5 to 1 g IV)
      3. Kolkebeck (2004) J Emerg Med 26(4): 395-400 [PubMed]
  4. Oral dosing after intravenous rate control
    1. Consider Beta Blocker for chronic rate control (more efficacious than oral Diltiazem)
    2. Diltiazem regular 30-60 mg orally four times daily as a start (titrating to 120 to 360 mg daily)

IX. Dosing: Hypertension

  1. Regular: 30 mg orally four times daily (MAX 360 mg/day)
  2. Extended: 180-240 mg orally daily (MAX 540 mg/day)

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Cost: Medications

diltiazem (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
DILTIAZEM 120 MG TABLET Generic $0.32 each
DILTIAZEM 12HR ER 120 MG CAP Generic $3.60 each
DILTIAZEM 12HR ER 60 MG CAP Generic $2.12 each
DILTIAZEM 12HR ER 90 MG CAP Generic $2.59 each
DILTIAZEM 24HR CD 120 MG CAP Generic $0.30 each
DILTIAZEM 24HR CD 180 MG CAP Generic $0.30 each
DILTIAZEM 24HR CD 240 MG CAP Generic $0.39 each
DILTIAZEM 24HR CD 300 MG CAP Generic $0.70 each
DILTIAZEM 24HR CD 360 MG CAP Generic $6.73 each
DILTIAZEM 24HR ER 120 MG CAP Generic $0.30 each
DILTIAZEM 24HR ER 180 MG CAP Generic $0.30 each
DILTIAZEM 24HR ER 180 MG TAB Generic $2.18 each
DILTIAZEM 24HR ER 240 MG CAP Generic $0.39 each
DILTIAZEM 24HR ER 240 MG TAB Generic $2.20 each
DILTIAZEM 24HR ER 300 MG CAP Generic $0.70 each
DILTIAZEM 24HR ER 300 MG TAB Generic $3.30 each
DILTIAZEM 24HR ER 360 MG CAP Generic $6.73 each
DILTIAZEM 24HR ER 360 MG TAB Generic $3.62 each
DILTIAZEM 24HR ER 420 MG CAP Generic $1.32 each
DILTIAZEM 24HR ER 420 MG TAB Generic $3.76 each
DILTIAZEM 30 MG TABLET Generic $0.12 each
DILTIAZEM 60 MG TABLET Generic $0.19 each
DILTIAZEM 90 MG TABLET Generic $0.28 each
DILTIAZEM ER 120 MG CAPSULE Generic $0.45 each
DILTIAZEM ER 180 MG CAPSULE Generic $0.49 each
DILTIAZEM ER 240 MG CAPSULE Generic $0.54 each
cardizem (on 10/19/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
CARDIZEM LA 120 MG TABLET $3.66 each
cartia (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
CARTIA XT 120 MG CAPSULE Generic $0.30 each
CARTIA XT 180 MG CAPSULE Generic $0.30 each
CARTIA XT 240 MG CAPSULE Generic $0.39 each
CARTIA XT 300 MG CAPSULE Generic $0.70 each
taztia (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
TAZTIA XT 120 MG CAPSULE Generic $0.38 each
TAZTIA XT 180 MG CAPSULE Generic $0.41 each
TAZTIA XT 240 MG CAPSULE Generic $0.57 each
TAZTIA XT 300 MG CAPSULE Generic $0.68 each
TAZTIA XT 360 MG CAPSULE Generic $0.69 each

Ontology: Diltiazem (C0012373)

Definition (MSH) A benzothiazepine derivative with vasodilating action due to its antagonism of the actions of CALCIUM ion on membrane functions.
Definition (CHV) a drug used to treat high blood pressure and to control chest pain (angina)
Definition (NCI) A benzothiazepine derivative with anti-hypertensive, antiarrhythmic properties. Diltiazem blocks voltage-sensitive calcium channels in the blood vessels, by inhibiting the ion-control gating mechanisms, thereby preventing calcium levels increase by other revenues. Alternatively, it has been suggested that this agent also interferes with the release of calcium from the sarcoplasmic reticulum and inhibits the influx of extracellular calcium across both the myocardial and vascular smooth muscle cell membranes. The overall low calcium levels leads to dilatation of the main coronary and systemic arteries and decreasing myocardial contractility, decreased peripheral arterial resistance, improved oxygen delivery to the myocardial tissue, and decreased cardiac output.
Definition (CSP) substituted benzothiazepine with specific blocking activity against inward rectifying calcium channel.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D004110
SnomedCT 372793000, 59941008
LNC LP17238-4, MTHU006970
English Diltiazem, 1,5-Benzothiazepin-4(5H)-one, 3-(acetyloxy)-5-(2-(dimethylamino)ethyl)-2,3-dihydro-2-(4-methoxyphenyl)-, (2S-cis)-, diltiazem (medication), Diltiazem [Chemical/Ingredient], DILTIAZEM, diltiazem, Diltiazem (product), Diltiazem (substance)
Swedish Diltiazem
Czech diltiazem
Finnish Diltiatseemi
Russian DILTIAZEM, ДИЛТИАЗЕМ
Japanese クラルート, セレスナット, 塩酸ジルチアゼムR, ジルベイト, パレトナミン, フロッティ錠, ルチアノンR, Frotty錠, コーレン錠, パゼアジン, ヨウチアゼム, ナックレス, マルムネン, ミオカルジー, 塩酸ジルチアゼム, ヘマレキート, ミルプチン, ヒロスタスR, ヘルベッサー, カルナース, Cohlen錠, ジルチアゼム
Croatian DILTIAZEM
Polish Diltiazem
Spanish diltiacem (sustancia), diltiacem, diltiazem (producto), diltiazem (sustancia), diltiazem, Diltiazem
French Diltiazem
German Diltiazem
Italian Diltiazem
Portuguese Diltiazem

Ontology: Cardizem (C0700940)

Concepts Organic Chemical (T109) , Pharmacologic Substance (T121)
MSH D004110
English Cardizem, cardizem

Ontology: Benzothiazepine (C1320166)

Concepts Organic Chemical (T109)
SnomedCT 406767004
English benzothiazepines, benzothiazepine, Benzothiazepine (substance), Benzothiazepine
Spanish benzotiazepina (sustancia), benzotiazepina