From the Guidelines
For patients allergic to beta blockers, calcium channel blockers such as diltiazem and verapamil are the primary alternatives for rate control, as recommended by the 2024 ESC guidelines 1. When considering alternatives to beta blockers for rate control, it's essential to prioritize medications that can effectively manage heart rate without triggering allergic reactions.
- Calcium channel blockers like diltiazem and verapamil are preferred options, as they slow heart rate by decreasing conduction through the AV node, with dosing as outlined in the 2010 American Heart Association guidelines 1.
- Digoxin is another alternative, particularly useful in patients with heart failure, though it works more slowly and is less effective during exercise or high sympathetic states. Key considerations for these alternatives include:
- Non-dihydropyridine calcium channel blockers like verapamil and diltiazem, which effectively slow heart rate by decreasing conduction through the AV node.
- Digoxin, which increases vagal tone and directly affects the AV node, providing an additional option for rate control. The most recent guidelines from 2024 1 support the use of these alternatives, emphasizing the importance of effective rate control in managing atrial fibrillation.
From the FDA Drug Label
Beta-blockers: Concomitant therapy with beta-adrenergic blockers and verapamil may result in additive negative effects on heart rate, atrioventricular conduction and/or cardiac contractility.
Beta-blockers: Controlled and uncontrolled domestic studies suggest that concomitant use of diltiazem hydrochloride and beta-blockers is usually well tolerated
Alternative medications for rate control if someone is allergic to beta blockers are:
- Verapamil 2: a calcium channel blocker that can be used for rate control
- Diltiazem 3: a calcium channel blocker that can be used for rate control Note that Digoxin 4 may also be considered, but its use should be carefully monitored due to potential toxicity.
From the Research
Alternative Medications for Rate Control
If someone is allergic to beta blockers, there are alternative medications that can be used for rate control. These include:
- Calcium channel blockers, which can effectively lower blood pressure and are approved for treating angina or cardiac dysrhythmias 5
- Nondihydropyridine calcium channel blockers, such as diltiazem and verapamil, which can reduce the heart rate and are often used in patients with cardiac dysrhythmias or who need β-blockers 5, 6
- Digoxin, which can help to obtain satisfactory rate control in combination with a beta-blocker, especially in patients with hypotension or an absolute contraindication to beta-blocker treatment 7
Considerations for Specific Patient Groups
For patients with atrial fibrillation (AF) and heart failure (HF) with or without systolic dysfunction, nondihydropyridine calcium channel blockers may be contraindicated 7. However, in patients with HFpEF or AF, the use of nondihydropyridine calcium channel blockers, such as diltiazem and verapamil, may be associated with a lower risk of HF hospitalization compared to β blockers 8. In the acute setting of AF RVR and HFrEF, diltiazem may be a reasonable second-line option for rate control, although more data are needed to validate this conclusion 9.
Potential Side Effects and Interactions
High doses of dihydropyridine calcium channel blockers can cause edema, headache, flushing, and tachycardia, while high doses of verapamil can cause constipation 5. Diltiazem and verapamil also have important drug interactions with digoxin and cyclosporine, among others 5.