diltiazem (Rx)

Brand and Other Names:Cardizem, Cardizem CD, more...Cardizem LA, Cartia XT, Dilacor, Dilacor XR, Dilatrate, Diltazem, Diltazem CD, Dilt-CD, Diltia XT, Diltiaz, Diltiaz CD, Diltiaz SR, Diltiazem CD, Diltiazem SR, Dilzem, Taztia XT, Tiazac
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

capsule/tablet, extended release

  • 120mg
  • 180mg
  • 240mg
  • 300mg
  • 360mg
  • 420mg

injectable solution

  • 5mg/mL

powder for injection

  • 100mg

tablet

  • 30mg
  • 60mg
  • 90mg
  • 120mg
more...

Angina

Conventional: 30 mg PO q6hr; increased every 1 or 2 days until angina controlled (usually 180-360 mg/day PO divided q6-8hr); not to exceed 360 mg/day

Cardizem CD, Cartia XT, Dilt-CD: 120-180 mg/day PO; titrate over 7-14 days; maintenance range usually 120-320 mg/day; not to exceed 480 mg/day

DilacorXR, Dilt-XR: 120 mg/day PO; titrate after 7-14 days; maintenance range usually 120-320 mg/day; not to exceed 540 mg/day

Tiazac, Taztia XT: 120-180 mg/day PO; titrate after 7-14 days; maintenance range usually 120-320 mg/day; not to exceed 540 mg/day

Cardizem LA, Matzim LA: 180 mg/day PO; titrate after 14 days; maintenance range usually 120-320 mg/day; not to exceed 360 mg/day

Hypertension

Cardizem CD, Cartia XT, Dilt-CD: 180-240 mg/day PO; titrate after 14 days; maintenance range usually 180-420 mg/day; not to exceed 480 mg/day

Dilacor XR, Dilt-XR: 180-240 mg/day PO; titrate after 14 days; maintenance range usually 180-420 mg/day; not to exceed 540 mg/day

Tiazac, Taztia XT: 120-240 mg/day PO; titrate after 14 days; maintenance range usually 180-420 mg/day; not to exceed 540 mg/day

Cardizem LA, Matzim LA: 180-240 mg/day PO; titrate after 14 days; maintenance range usually 120-540 mg/day

Extended-release twice-daily dosing: 60-120 mg PO q12hr; may be adjusted after 14 days; maintenance range usually 240-360 mg/day

Paroxysmal Supraventricular Tachycardia

0.25 mg/kg (average adult dose, 20 mg) direct IV over 2 minutes; after 15 minutes, may repeat bolus by administering 0.35 mg/kg actual body weight over 2 min (average adult dose, 25 mg) direct IV if first dose tolerated but response inadequate; some clinicians suggest additional doses q15min  

Use weight-based dosing for lower-body-weight patients

Continuous infusion: 10 mg/hr IV initially; increased to no more than 15 mg/hr for up to 24 hours

Atrial Fibrillation/Flutter

0.25 mg/kg (usual adult dose, 20 mg) direct IV over 2 minutes; after 15 minutes, may repeat bolus by administering 0.35 mg/kg actual body weight over 2 min (average adult dose, 25 mg) direct IV if first dose tolerated but response inadequate; some clinicians suggest additional doses q15min 

Use weight-based dosing for lower-body-weight patients

Continuous infusion: 10 mg/hr IV initially; increased to no more than 15 mg/hr for up to 24 hours

Dose Modifications

Renal Impairment

  • Use caution; not studied

Hepatic Impairment

  • Use caution; not studied

Dosage Forms & Strengths

capsule/tablet, extended release

  • 120mg
  • 180mg
  • 240mg
  • 300mg
  • 360mg
  • 420mg

injectable solution

  • 5mg/mL

powder for injection

  • 100mg

tablet

  • 30mg
  • 60mg
  • 90mg
  • 120mg
more...

Hypertension (Off-label)

1.5-2 mg/kg/day PO divided q8hr; not to exceed 6 mg/kg/day, up to 360 mg/day 

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Interactions

Interaction Checker

and diltiazem

No Results

     activity indicator 
    No Interactions Found
    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

          Minor

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            Adverse Effects

            >10%

            Edema (2-15%)

            Headache (5-12%)

            1-10%

            Dizziness (3-10%)

            AV block (2-8%)

            Peripheral edema (2-8%)

            Bradyarrhythmia (2-6%)

            Headache (1-5%)

            Hypotension (2-4%)

            Nausea (3%)

            Vomiting (2%)

            Vasodilation (2-3%)

            Extrasystoles (2%)

            Flushing (1-2%)

            Drug-induced gingival hyperplasia (<2%)

            Myalgia (2%)

            Diarrhea (1-2%)

            Constipation (2-4%)

            Bronchitis (1-4%)

            Sinus congestion (1-2%)

            Dyspnea (1-6%)

            Congestion (1-2%)

            < 1%

            Increased Alkaline phosphatase as well as ALT and AST

            CHF

            Thrombocytopenia

            Toxic epidermal necrolysis

            Hemolytic anemia

            Photosensitivity

            Extrapyramidal symptoms

            Syncope

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            Warnings

            Contraindications

            Hypersensitivity

            Wolff-Parkinson-White syndrome, Lown-Ganong-Levine syndrome, symptomatic severe hypotension (systolic BP <90 mm Hg), sick sinus syndrome (if no pacemaker), 2°/3&deg (if no pacemaker); heart block

            PO: Acute MI and pulmonary congestion

            IV: Use in newborns (because of benzyl alcohol), concomitant beta-blocker therapy, cardiogenic shock, ventricular tachycardia (must determine whether origin is supraventricular or ventricular)

            Cautions

            May cause abnormally slow heart rates or second- or third-degree AV block’ patients with sick sinus syndrome are at increased risk of bradycardia (risk increases with agents known to slow cardiac conduction

            Stevens-Johnson syndrome, toxic epidermal necrolusis, erythema multiforme and/or exfoliative dermatitis reported

            Significant elevations in liver enzymes such as alkaline phosphatase, LDH, AST (SGOT), ALT (SGPT) and signs of acute hepatic injury reported; reversible upon discontinuation of drug therapy

            Mild elevations of transaminases with and without concomitant elevation in alkaline phosphatase and bilirubin observed; elevations were usually resolved even with continued diltiazem treatment

            Symptomatic hypotension with or without syncope reported

            Peripheral edema occurs within 2-3 weeks of starting therapy

            Use with caution in hypertrophic obstructive cariomyopathy, hepatic/renal impairment, left ventricular dysfunction

            Concomitant use of diltiazem with beta-blockers or digitalis may result in additive effects on cardiac conduction; sinus bradycardia resulting in hospitalization reported with concurrent use of clonidine and other agents that slow cardiac conduction

            May increase the risk of adverse cardiac events in patients with heart failure due to negative inotropic effects (risk directly related to the severity of baseline HF)

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            Pregnancy & Lactation

            Pregnancy category: C

            Lactation: Drug enters breast milk; because of risk for serious adverse reactions in nursing infants from diltiazem, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother

            Pregnancy Categories

            A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA:Information not available.

            more...
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            Pharmacology

            Mechanism of Action

            Nondihydropyridine calcium-channel blocker: Inhibits extracellular calcium ion influx across membranes of myocardial cells and vascular smooth muscle cells, resulting in inhibition of cardiac and vascular smooth muscle contraction and thereby dilating main coronary and systemic arteries; no effect on serum calcium concentrations; substantial inhibitory effects on cardiac conduction system, acting principally at AV node, with some effects at sinus node

            Absorption

            Bioavailability: 40% (PO)

            Onset (hypertension): 30-60 min (IR); 3 min (IV)

            Duration (SVT): 1-3 hr (IV bolus); 0.5-10 hr (following discontinuation of continuous IV infusion)

            Peak serum time: 2-4 hr (IR); 10-14 hr (ER capsule); 11-18 hr (ER tablet)

            Distribution

            Protein bound: 70-80%

            Vd: 3-13 L/kg

            Metabolism

            Metabolized via hepatic CYP3A4

            Metabolites: Desacetyldiltiazem (active), 25-50% as potent as diltiazem in coronary vasodilation; N-monodesmethyldiltiazem (inactive)

            Elimination

            Half-life: 3-4.5 hr (IR); 6-9 hr (ER tablet), 5-10 hr (ER capsule); 3-4 hr (single dose IV); 4-5 hr (continuous infusion)

            Clearance: 11.8 mL/min/kg

            Excretion: Urine (2-4% as unchanged; 6-7% as metabolites), feces

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            Administration

            IV Incompatibilities

            Y-site: Allopurinol, amphotericin B, cefepime, cefoperazone, diazepam, furosemide, ketorolac, lansoprazole, pantoprazole, phenytoin, rifampin, thiopental

            IV Compatibilities

            Solution: D5W, NS

            Y-site (partial list): Acetazolamide (may be incompatible at higher concentrations), acyclovir (may be incompatible at higher concentrations), ceftriaxone, ciprofloxacin, clindamycin, digoxin, dobutamine, dopamine, epinephrine, erythromycin, fentanyl, fluconazole, heparin(?), labetalol, lidocaine, lorazepam, meperidine, metoclopramide, metronidazole, midazolam, milrinone, morphine sulfate, nafcillin (may be incompatible at higher concentrations), nitroglycerin, norepinephrine, potassium chloride, sodium bicarbonate, vancomycin

            IV Preparation

            IV push may be given by using undiluted 5 mg/mL injection

            Infusion

            • Accepted diluents are D5W, NS, and D5/½NS
            • Add 25 mL of 5 mg/mL solution in 100 mL diluent (1 mg/mL solution)
            • Add 50 mL of 5 mg/mL solution in 250 mL diluent (0.83 mg/mL solution)
            • Add 50 mL of 5 mg/mL solution in 500 mL diluent (0.45 mg/mL solution)
            • Dilute 1 monovial (100 mg) in 100 mL diluent (1 mg/mL solution)
            • Dilute 2 monovials (200 mg) in 250 mL diluent (0.8 mg/mL solution)
            • Dilute 2 monovials (200 mg) in 500 mL diluent (0.4 mg/mL solution)

            IV Administration

            Give bolus over 2 minutes with continuous ECG and BP monitoring

            Response to bolus may require several minutes to reach maximum; response may persist for several hours after infusion is discontinued

            Continuous infusion is done via infusion pump

            Infusion for >24 hours is not recommended

            Storage

            Refrigerate liquid injection vials; protect from freezing

            May store at room temperature for 1 month

            Powder: Store at room temperature; do not freeze

            Reconstituted solution stable at room temperature for 24 hours

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            Formulary

            FormularyPatient Discounts

            Adding plans allows you to compare formulary status to other drugs in the same class.

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            • View the formulary and any restrictions for each plan.
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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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