Calcium Channel PDF

Detail-Document #250414
−This Detail-Document accompanies the related article published in−

PHARMACIST’S LETTER / PRESCRIBER’S LETTER
April 2009 ~ Volume 25 ~ Number 250414
Comparison of Calcium Channel Blockers

Calcium channel blockers (CCBs) are divided into two classes: the non-dihydropyridines (diltiazem [e.g., Cardizem, etc] and verapamil [e.g.,
Calan, etc]) and the dihydropyridines (all CCBs except verapamil and diltiazem). The following chart provides information on the pharmacology and
therapeutic interchange for the CCBs in the U.S. Many states allow therapeutic interchange without prescriber approval of therapeutic equivalents as
listed in the FDA’s Orange Book. Therapeutic equivalents are drugs that demonstrate BOTH pharmaceutical equivalence (same active ingredient,
dosage form, and strength) and bioequivalence (comparable rate and extent of absorption). (See our Detail-Document “Generic Substitution for
Commonly Prescribed Drugs” for information about generic substitution of other drugs and for a chart of state substitution regulations). The chart
below does not include “authorized generics.” Authorized generics are the exact same product as the brand name, but marketed as a generic (e.g.,
Pfizer’s nifedipine ER tablet is the same as Procardia XL).
Abbreviations: A. fib-atrial fibrillation; A. flutter-atrial flutter; ER-extended release; HS-at bedtime; HTN-hypertension; IR-immediate release; mfr-
manufacturer; SVT-supraventricular tachycardia
Drug4-38 Formulation/ Therapeutic Equivalentsa Indication and Doseb Commentsb

Strength (Drug/Mfr)
DIHYDROPYRIDINES: Mechanism of action involves coronary and peripheral arteriolar vasodilation. This can lead to reflex tachycardia, headache,
flushing, and peripheral edema. The dihydropyridines can impair myocardial contractility to varying degrees.1 Dihydropyridines are CYP3A4 substrates.2
Once-a-day (24 hour) Dihydropyridines
Amlodipine (Norvasc) 2.5 mg, 5 mg, Amlodipine tablet HTN: initial 5 mg QD (2.5 mg QD for May be the safest choice if
10 mg tablets Actavis Totowa, Amneal, small, frail, elderly, or hepatic a CCB is needed in a
Apotex, Aurobindo, insufficiency); max patient with systolic heart
Caraco, Cobalt, Dr. 10 mg QD failure.1
Reddy’s, Gedeon Richter, CAD: 5 mg to 10 mg QD
Invagen, Kali, Lek, Lupin,
Matrix, Mylan, Ranbaxy,
Roxane, Synthon, Teva,
Torrent, Upsher Smith,
Watson, Wockhardt, Zydus
More. . .
Copyright © 2009 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
(Detail-Document #250414: Page 2 of 10)

Strength (Drug/Mfr)
Once-a-day (24 hour) Dihydropyridines, continued
Felodipine ER (Plendil) 2.5 mg, 5 mg, Felodipine ER tablet HTN: initial 5 mg QD (2.5 mg QD
10 mg tablet Mutual, Mylan elderly); max 10 mg QD
Isradipine ER (DynaCirc CR) 5 mg, 10 mg Nonec HTN: 5 mg QD; max 20 mg per day Patients may have more
tablet side effects with no
additional benefit at doses
>10 mg daily.
Nifedipine ER (Adalat CC) 30 mg, 60 mg Nifedipine ER tablet HTN: initial 30 mg QD; doses >90 mg Take on an empty stomach.
tablet Actavis, Afeditab CR not recommended
(Watson), Biovail
(marketed by Teva as
Nifediac CC)
90 mg Biovail (marketed by Teva

as Nifediac CC)
Nifedipine ER (Afeditab CR) 30 mg, 60 mg Nifedipine ER tablet HTN: initial 30 mg QD; doses >90 mg Take on an empty stomach.
tablet Actavis, Adalat CC not recommended
(Bayer), Biovail (marketed
by Teva as Nifediac CC)
Nifedipine ER (Procardia XL) 30 mg, 60 mg Nifedipine ER tablet HTN: initial 30-60 mg QD; max
tablet Biovail (marketed by Teva 120 mg QD
as Nifedical XL), Osmotica
Vasospastic or chronic stable angina:
90 mg tablet Nifedipine ER tablet initial
Osmotica 30-60 mg QD; max
120 mg QD (limited experience with
>90 mg QD)
More. . .

Strength (Drug/Mfr)
Once-a-day (24 hour) Dihydropyridines, continued
Nisoldipine ER (Sular) 8.5 mg, 17 mg, Nonec HTN: initial 17 mg QD; max 34 mg
25.5 mg, 34 mg QD
tablet
Nisoldipine ER (generic only; 20 mg, 30 mg, None HTN: initial 20 mg QD; usual Increased risk of adverse
brand to which it was 40 mg tablet 20-40 mg QD; max 60 mg QD effects over 40 mg.
equivalent has been
reformulated) (Mylan)
Twice Daily Dihydropyridines

Isradipine (DynaCirc [brand 2.5 mg, 5 mg Isradipine capsule HTN: initial 2.5 mg BID; max daily Patients may have more
discontinued], generics capsule Actavis, Cobalt dose 20 mg (given in divided doses) side effects with no
available) additional benefit with
>10 mg daily.
Nicardipine ER (Cardene SR) 30 mg, 45 mg, Nonec HTN: usual 30-60 mg twice daily
60 mg capsule
Three Times Daily Dihydropyridines

Nicardipine (Cardene [brand 20 mg, 30 mg Nicardipine capsule HTN: initial 20 mg TID; usual Start with 20 mg BID in
discontinued], generics capsule Amneal, Barr, Mylan, 20-40 mg TID hepatic insufficiency.
available) Teva, Watson
Chronic stable angina: initial 20 mg
TID; usual 20-40 mg TID
Nifedipine IR (Procardia) 10 mg, 20 mg Nifedpine capsule Vasospastic or chronic stable angina: Not to be used to treat acute
capsule Actavis Elizabeth, Catalent, initial blood pressure elevation or
Inverness 10 mg TID; usual hypertension.
10-20 mg TID;
max 60 mg TID
More. . .

Strength (Drug/Mfr)
NON-DIHYDROPYRIDINES: Compared to the dihydropyridines, the non-dihydropyridines provide relatively less peripheral and coronary arteriolar
vasodilation. They have significant negative inotropic and negative chronotropic effects, with verapamil having the most pronounced effect. The non-
dihydropyridines also slow cardiac conduction.1 Diltiazem and verapamil are CYP3A4 substrates and CYP3A4 inhibitors.2 Constipation is common with
verapamil.1
Once-a-day (24 hour) Non-dihydropyridine Products
Diltiazem ER (Cardizem CD) 120 mg, 180 mg, Diltiazem ER capsule HTN: initial 180-240 mg QD; usual Capsules can be opened for
240 mg, 300 mg Actavis Elizabeth, Biovail, 240-360 mg QD; max 480 mg QD administration of the intact
capsule Cartia XT (Watson Labs granules.3
Florida), Dilt-CD Vasospastic and chronic stable angina:
(Torpharm) 120-180 mg QD; max Some patients may respond
480 mg QD to lower dose.
360 mg capsule Nonec
Diltiazem ER (Cardizem LA) 120 mg, 180 mg, Nonec HTN: initial 180-240 mg QD; max Some patients may respond
240 mg, 300 mg, 540 mg QD to lower dose.
360 mg, 420 mg
tablet Chronic stable angina: initial
180 mg QD; max 360 mg QD
Diltiazem ER (Cartia XT) 120 mg, 180 mg, Diltiazem ER capsule HTN:initial 180-240 mg QD; usual Some patients may respond
240 mg, 300 mg Actavis Elizabeth, Biovail, 240-360 mg QD; max 480 mg QD to lower dose.
capsule Cardizem CD (Biovail),
Dilt-CD (Torpharm) Vasospastic and chronic stable angina:
initial 120-180 mg QD; max 480 mg
QD
Diltiazem ER (Dilacor XR) 120 mg, 180 mg, Diltiazem ER capsule HTN: initial 180-240 mg (elderly
240 mg capsule Watson Labs Florida, 120 mg QD); usual 180-480 mg QD;
Mylan, Torpharm max 540 mg QD
Chronic stable angina: initial 120 mg

QD; max 480 mg QD
More. . .

Strength (Drug/Mfr)
Once-a-day (24 hour) Non-dihydropyridine Products, continued
Diltiazem ER (Dilt-CD) 120 mg, 180 mg, Diltiazem ER capsule HTN: initial 180-240 mg QD; usual Some patients may respond
240 mg, 300 mg Actavis Elizabeth, Biovail, 240-360 mg QD; max 480 mg QD to lower dose.
capsule Cardizem CD (Biovail),
Cartia XT (Watson Labs Vasospastic and chronic stable angina:
Florida) initial 120-180 mg QD; max 480 mg
QD
Diltiazem ER (Diltzac) 120 mg, 180 mg, Diltiazem ER capsule HTN: initial 120-240 mg QD; max May administer capsule
240 mg, 300 mg, KV Pharm, Taztia XT 540 mg QD contents sprinkled on a
360 mg capsule (Watson Labs Florida), spoonful of applesauce,
Tiazac (Biovail) Chronic stable angina: initial followed by a glass of cool
120-180 mg QD; max 540 mg QD water; do not chew.
Diltiazem ER (Taztia XT) 120 mg, 180 mg, Diltiazem ER capsule HTN: initial 120-240 mg QD; max May administer capsule
240 mg, 300 mg, KV Pharm, Diltzac 540 mg QD contents sprinkled on a
360 mg capsule (Apotex), spoonful of applesauce,
Tiazac (Biovail) Chronic stable angina: initial followed by a glass of cool
120-180 mg QD; max 540 mg QD water; do not chew.
Diltiazem ER (Tiazac) 120 mg, 180 mg, Diltiazem ER capsule HTN: initial 120-240 mg QD; May administer capsule
240 mg, 300 mg KV Pharm, Diltzac max 540 mg QD contents sprinkled on a
capsule (Apotex), spoonful of applesauce,
Taztia XT (Watson Labs Chronic stable angina: followed by a glass of cool
Florida) initial 120-180 mg QD; max 540 mg water; do not chew.
420 mg capsule Diltiazem ER capsule QD
KV Pharm
Verapamil ER (Verelan) 120 mg, 180 mg, Verapamil ER capsule HTN: 240 mg QD (120 mg QD for May administer capsule
240 mg capsule Mylan small or elderly patients, or those with contents sprinkled on a
liver impairment); max 480 mg QD spoonful of applesauce,
360 mg capsule None followed by a glass of cool
water; do not chew.
More. . .
Drug4-38 Formulation/ Therapeutic Indication and Doseb Commentsb

Strength Equivalentsa (Drug/Mfr)
Once-a-day (24 hour) Non-dihydropyridine Products, continued
Verapamil ER (Verelan PM) 100 mg, Verapamil ER capsule HTN: 200 mg HS (100 mg HS for May administer capsule
200 mg, 300 mg Mylan small or elderly patients, or renal or contents sprinkled on a
capsule hepatic insufficiency); max 400 mg HS spoonful of applesauce,
followed by a glass of cool
water; do not chew.
Taken HS, peak effect

occurs in morning & early
afternoon.
Verapamil ER (Covera-HS) 180 mg, 240 mg Nonec HTN: initial 180 mg QD; max 480 mg Taken HS, peak verapamil
tablet QD plasma concentrations
occur in the early morning
Angina: initial 180 mg QD; max hours.
540 mg QD
Twice-a-day (12 hour) Non-dihydropyridine Products
Diltiazem ER (formerly 60 mg, 90 mg, Diltiazem ER capsule HTN: initial 60-120 mg BID; usual
Cardizem SR [discontinued]; 120 mg capsule Mylan daily dose 240-360 mg (given in
generic available) divided doses)
Verapamil ER (Isoptin SR) 120 mg, 240 mg Ivax, Kali, Mylan HTN: initial 180 mg QD (consider
tablet 120 mg in small or elderly patients, or
hepatic insufficiency); max 240 mg Q12
180 mg tablet Ivax, Mylan hrs
More. . .

Strength (Drug/Mfr)
Three and Four times daily Non-dihydropyridine Products
Diltiazem IR (Cardizem) 30 mg, 60 mg, Diltiazem IR tablet Vasospastic and chronic stable angina: Take before meals and at
120 mg, 90 mg Clonmel, Mylan, Teva initial 30 mg QID; average daily dose bedtime.
tablet 180-360 mg (given in divided doses)
Verapamil IR (Calan) 40 mg tablet Verapamil IR tablet HTN: initial 80 mg TID (consider

Sandoz, Watson 40 mg TID in small or elderly patients,
or hepatic impairment); max daily dose
480 mg (given in divided doses)(no
evidence of additional benefit beyond
360 mg)
80 mg, 120 mg Verapamil IR tablet
tablet Actavis Elizabeth, Mylan, Vasospastic and chronic stable angina:
Sandoz, Watson usual 80-120 mg TID; consider initial
dose of 40 mg TID in small or elderly,
or hepatic impairment.
A.fib, A.flutter: 80 mg TID to 80 mg

QID (with digoxin)
SVT: 80 mg TID to 120 mg QID (non-

digitalized)
Acute Care Calcium Channel Blockers

Clevidipine (Cleviprex) 0.5 mg/mL None Blood pressure reduction: initial 1-2 Also see our Detail-
emulsion mg/hour; usual 4-6 mg/hr Document: “New Drug:
Cleviprex (Clevidipine)”
More. . .

Strength (Drug/Mfr)
Acute Care Calcium Channel Blockers, continued
Diltiazem (Cardizem) injection 5 mg/mL Diltiazem injection A. fib and A. flutter: 0.25 mg/kg Diltiazem exhibits dose-
(brand discontinued, generic Apotex, Baxter, Bedford, (20 mg for average size patient) over 2 dependent, non-linear
available) Hospira, Intl Medication, min; after 15 min., if needed, give kinetics, and may
Taylor, Teva 0.35 mg/kg (25 mg for average size accumulate with infusion
100 mg/15 mL Diltiazem injection patient); if needed give additional for more than 24 hours.
Add-Vantage vial Hospira boluses or start continuous infusion of
10 mg/hour (range 5-15 mg/hour) for up
to 24 hours
SVT: 0.25 mg/kg (20 mg for average

size patient) over 2 min; after 15 min.,
if needed, give 0.35 mg/kg (25 mg for
average size patient); subsequent doses
per patient need
Nicardipine injection (Cardene) 2.5 mg/mL Nicardipine injection HTN: initial 5 mg/hour, max
Teva 15 mg/hour; decrease to 3 mg/hour
when goal reached
20 mg (0.1 Nicardipine injection
mg/mL), 40 mg EKR Therapeutics As a substitute for oral nicardipine:
(0.2 mg/mL) 20 mg Q8hrs=0.5 mg/hour;
premix 30 mg Q8hrs=1.2 mg/hour;
40 mg Q8hrs=2.2 mg/hour
Nimodipine (Nimotop [brand 30 mg capsules Nimodipine capsules Subarachnoid hemorrhage: 60 mg Can puncture capsule on
discontinued, generic Banner, Barr, Sun Q4 hours for 21 days both ends and withdraw
available]) contents with 18-guage
needle & administer
through nasogastric tube
followed by 30 mL of
water. Label syringe “Not
for IV use.”
More. . .

Strength (Drug/Mfr)
Acute Care Calcium Channel Blockers, continued
Verapamil injection (Calan 2.5 mg/mL Verapamil injection SVT, A.fib., A.flutter: initial Infuse over at least 3 min.
[brand discontinued, generic Bedford, Hospira, Intl 5-10 mg (0.075-0.15 mg/kg) over 2 in elderly patients.
available]) Medication, Luitpold min; if needed, after 30 min., give
10 mg (0.15 mg/kg); optimal interval
for subsequent doses not determined
a. From Electronic Orange Book. March 13, 2009. http://www.fda.gov/cder/ob/default.htm. (Accessed March 14, 2009). The manufacturers
listed may differ from the company who markets or distributes the drug. Both the manufacturer and distributor are listed on the drug’s
product labeling.
b. From U.S. prescribing information unless otherwise specified.
c. Cost of 30-day supply (drugstore.com): Cardene SR 60 mg BID $125.99; Cardizem CD 360 mg QD $215.23; Cardizem LA 360 mg QD
$133.78; Covera HS 240 mg HS $79.37; DynaCirc CR 10 mg QD $159.73; Sular 34 mg QD $92.38; Verelan 360 mg QD $191.20.
Users of this document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical
judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national
organizations. Information and Internet links in this article were current as of the date of publication.
More. . .
Project Leader in preparation of this Detail- 19. Product information for Cardizem LA. Abbott
Document: Melanie Cupp, Pharm.D., BCPS Laboratories. North Chicago, IL 60064. September
2007.
20. Product information for Cartia XT. Watson
References Laboratories, Inc. Corona, CA 92880. December
1. Saseen JJ, Carter BL. Essential hypertension. In: 2006.
Koda-Kimble MA, Young LY, Kradjan WA, Gugliemo 21. Product information for Dilt-CD. Apotex Corp.
BJ, editors. Applied therapeutics: the clinical use of Weston, FL 33326. May 2004.
drugs. Philadelphia, PA: Lippincott Williams & 22. Product information for Dilt-XT. Apotex Corp.
Wilkins; 2005. Weston, FL 33326. September 2005.
2. Cytochrome P450 drug interactions. Pharmacist's 23. Product information for Diltzac. Apotex Corp.
Letter/Prescriber's Letter 2006;22(2):220233. Weston, FL 33326. July 2008.
3. Medications that should not be crushed. 24. Product information for Diltia XT. Watson
Pharmacist's Letter/Prescriber's Letter Laboratories, Inc. Corona, CA 92889. July 2007.
2008;24(12):241204. 25. Product information for Taztia XT. Watson
4. Product information for Norvasc. Pfizer Inc. NY, NY Laboratories. Corona, CA 92880. December 2006.
10017. August 2006. 26. Product information for Tiazac. Forest
5. Product information for Plendil. AstraZeneca LP. Pharmaceuticals, Inc. St. Louis, MO 63045. April
Wilmington, DE 19850. November 2003. 2006.
6. Product information for DynaCirc CR. Reliant 27. Product information for Verelan. Schwarz Pharma.
Pharmaceuticals, Inc. Liberty Corner, NJ 07938. Milwaukee, WI 53201. March 2005.
August 2005. 28. Product information for Verelan PM. Schwarz
7. Product information for Adalat CC. Schering Pharma. Milwaukee, WI 53201. May 2004.
Corporation. Kenilworth, NJ 07033. October 2004. 29. Product information for Covera-HS. Pfizer In. NY,
8. Product information for Afeditab CR. Watson NY 10017. March 2006.
Laboratories. Corona, CA 92880. September 2007. 30. Product information for diltiazem extended-release
9. Product information for Nifediac CC. Teva capsule (twice-a-day dosage). Mylan
Pharmaceuticals USA. Sellersville, PA 18960. July Pharmaceuticals Inc. Morgantown, WV 26505. June
2003. 2006.
10. Product information for Nifedical XL. Teva 31. Product information for Isoptin SR. Ranbaxy
Pharmaceuticals USA. Sellersville, PA 18960. Laboratories Inc. Jacksonville, FL 32257. July 2007.
September 2003. 32. Product information for Cardizem. Biovail
11. Product information for Procardia XL. Pfizer Inc. Pharmaceuticals, Inc. Morrisville, NC 27560.
NY, NY 10017. August 2003. August 2001.
12. Product information for Sular. Sciele Pharma, Inc. 33. Product information for Calan. Pfizer Inc. NY, NY
Atlanta, GA 30328. January 2008. 10017. May 2006.
13. Product information for nisoldipine. Mylan 34. Product information for Cleviprex. The Medicines
Pharmaceuticals Inc. Morgantown, WV 26505. June Company. Parsippany, NJ 07054. August 2008.
2008. 35. Product information for diltiazem injection. Bedford
14. Product information for isradipine. Cobalt Laboratories. Bedford, OH 44146. May 2005.
Laboratories. Bonita Springs, FL 34134. May 2008. 36. Product information for nicardipine injection. EKR
15. Product information for Cardene SR. PDL Therapeutics, Inc. Bedminster, NJ 07921. May
BioPharma, Inc. Redwood City, CA 94063. January 2008.
2007. 37. Product information for nimodipine. Barr
16. Product information for nicardipine. Mylan Laboratories, Inc. Pomona, NY 10970. February
Pharmaceuticals Inc. Morgantown, WV 26505. 2007.
December 2004. 38. Product information for verapamil injection. Hospira,
17. Product information for Procardia. Pfizer Inc. NY, Inc. Lake Forest, IL 60045. June 2005.
NY 10017. March 2006.
18. Product information for Cardizem CD. Biovail
Pharmaceuticals, Inc. Morrisville, NC 27560.
August 2001.
Cite this Detail-Document as follows: Comparison of calcium channel blockers. Pharmacist’s Letter/Prescriber’s
Letter 2009;25(4):250414.
Evidence and Advice You Can Trust…

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Detail-Document #250414

−This Detail-Document accompanies the related article published in−

Comparison of Calcium Channel Blockers

Drug4-38 Formulation/ Therapeutic Equivalentsa Indication and Doseb Commentsb

Drug4-38 Formulation/ Therapeutic Equivalentsa Indication and Doseb Commentsb

90 mg Biovail (marketed by Teva

Drug4-38 Formulation/ Therapeutic Equivalentsa Indication and Doseb Commentsb

Twice Daily Dihydropyridines

Three Times Daily Dihydropyridines

Drug4-38 Formulation/ Therapeutic Equivalentsa Indication and Doseb Commentsb

Chronic stable angina: initial 120 mg

Drug4-38 Formulation/ Therapeutic Equivalentsa Indication and Doseb Commentsb

Drug4-38 Formulation/ Therapeutic Indication and Doseb Commentsb

Taken HS, peak effect

Twice-a-day (12 hour) Non-dihydropyridine Products

Drug4-38 Formulation/ Therapeutic Equivalentsa Indication and Doseb Commentsb

Verapamil IR (Calan) 40 mg tablet Verapamil IR tablet HTN: initial 80 mg TID (consider

A.fib, A.flutter: 80 mg TID to 80 mg

SVT: 80 mg TID to 120 mg QID (non-

Acute Care Calcium Channel Blockers

Drug4-38 Formulation/ Therapeutic Equivalentsa Indication and Doseb Commentsb

SVT: 0.25 mg/kg (20 mg for average

Drug4-38 Formulation/ Therapeutic Equivalentsa Indication and Doseb Commentsb

Evidence and Advice You Can Trust…

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