Diltiazem

Aka: Diltiazem, Cardizem, Benzothiazapine, Cartia, Taztia, Tiazac

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II. Class

  1. Non-Dihydropyridine Calcium Channel Blocker

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. Hypertension
    1. Consider Dihydropyridine Calcium Channel Blocker (e.g. Amlodipine) instead if Heart Rate control not needed
  2. Atrial Fibrillation with Rapid Ventricular Response
    1. Highly effective at controlling ventricular rate
  3. Paroxysmal Supraventricular Tachycardia
    1. Less studied than Verapamil for PSVT
  4. Supraventricular Tachycardia
    1. Terminates AV Node reentry Tachycardias

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)
    1. Long-acting formulations have variable release mechanisms and dosing regimens vary between products

X. Adverse Effects

  1. See Calcium Channel Blocker

XI. References

  1. (2022) Presc Lett 29(11): 64-5

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Related Studies

Cost: Medications

diltiazem (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
DILTIAZEM 120 MG TABLET Generic $0.28 each
DILTIAZEM 12HR ER 120 MG CAP Generic $3.33 each
DILTIAZEM 12HR ER 60 MG CAP Generic $2.03 each
DILTIAZEM 12HR ER 90 MG CAP Generic $2.31 each
DILTIAZEM 24H ER(CD) 120 MG CP Generic $0.14 each
DILTIAZEM 24H ER(CD) 180 MG CP Generic $0.20 each
DILTIAZEM 24H ER(CD) 240 MG CP Generic $0.24 each
DILTIAZEM 24H ER(CD) 300 MG CP Generic $0.30 each
DILTIAZEM 24H ER(CD) 360 MG CP Generic $0.66 each
DILTIAZEM 24H ER(LA) 180 MG TB Generic $2.08 each
DILTIAZEM 24H ER(LA) 240 MG TB Generic $2.23 each
DILTIAZEM 24H ER(LA) 360 MG TB Generic $3.12 each
DILTIAZEM 24H ER(XR) 120 MG CP Generic $0.44 each
DILTIAZEM 24H ER(XR) 180 MG CP Generic $0.53 each
DILTIAZEM 24H ER(XR) 240 MG CP Generic $0.75 each
DILTIAZEM 24HR ER 120 MG CAP Generic $0.26 each
DILTIAZEM 24HR ER 180 MG CAP Generic $0.29 each
DILTIAZEM 24HR ER 240 MG CAP Generic $0.48 each
DILTIAZEM 24HR ER 300 MG CAP Generic $0.59 each
DILTIAZEM 24HR ER 360 MG CAP Generic $0.56 each
DILTIAZEM 24HR ER 420 MG CAP Generic $0.95 each
DILTIAZEM 30 MG TABLET Generic $0.09 each
DILTIAZEM 60 MG TABLET Generic $0.17 each
DILTIAZEM 90 MG TABLET Generic $0.24 each
cardizem (on 2/23/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
CARDIZEM LA 120 MG TABLET $3.66 each
cartia (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
CARTIA XT 120 MG CAPSULE Generic $0.14 each
CARTIA XT 180 MG CAPSULE Generic $0.20 each
CARTIA XT 240 MG CAPSULE Generic $0.24 each
CARTIA XT 300 MG CAPSULE Generic $0.30 each
taztia (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
TAZTIA XT 120 MG CAPSULE Generic $0.26 each
TAZTIA XT 180 MG CAPSULE Generic $0.29 each
TAZTIA XT 240 MG CAPSULE Generic $0.48 each
TAZTIA XT 300 MG CAPSULE Generic $0.59 each
TAZTIA XT 360 MG CAPSULE Generic $0.56 each
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

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