What is a good alternative for diltiazem 180mg Extended Release?

Best Alternatives for Diltiazem 180mg Extended Release

For patients currently taking diltiazem 180mg ER, the best alternative is verapamil extended-release, starting at 180mg once daily in the morning. 1 This provides similar pharmacological effects while maintaining the once-daily dosing convenience.

First-Line Alternatives

Non-dihydropyridine Calcium Channel Blockers

• Verapamil ER:
  • Starting dose: 180mg once daily in the morning 1
  • Can be titrated up to 240mg daily if needed
  • Provides similar heart rate control and anti-anginal effects as diltiazem
  • Comparable efficacy in hypertrophic cardiomyopathy 2

Beta-Blockers

• Excellent alternatives when diltiazem is discontinued:
  • Metoprolol succinate: 50mg once daily (can be titrated up to 400mg daily) 3
  • Metoprolol tartrate: 25mg twice daily (can be titrated up to 200mg twice daily) 3
  • Carvedilol: 3.125-6.25mg twice daily (titrate as needed)

Clinical Decision Algorithm

1. If patient has stable angina or hypertension:

   • First choice: Verapamil ER 180mg daily 1
   • Second choice: Beta-blocker (metoprolol or carvedilol) 3

2. If patient has atrial fibrillation/flutter:

   • First choice: Beta-blocker 3
   • Second choice: Verapamil ER (if beta-blockers contraindicated) 3

3. If patient has hypertrophic cardiomyopathy:

   • First choice: Non-vasodilating beta-blocker 3
   • Second choice: Verapamil ER (shown to have comparable effects to diltiazem) 2

4. If patient has supraventricular tachycardia:

   • First choice: Beta-blocker 3
   • Second choice: Verapamil ER 3

Important Considerations

Cautions When Switching

• Avoid combining verapamil with beta-blockers due to risk of severe bradycardia, heart block, or heart failure 3
• Avoid dihydropyridine CCBs alone (like nifedipine, amlodipine) in patients with angina without concomitant beta-blockade 3
• Monitor closely during transition, especially in elderly patients or those with heart failure

Contraindications for Verapamil

• Severe left ventricular dysfunction
• Hypotension
• Sick sinus syndrome or high-degree AV block without pacemaker
• Concomitant use with CYP3A4 substrates (may increase drug levels) 4

Special Populations

• Elderly patients: Consider starting with lower doses of verapamil (120mg daily)
• Patients with heart failure: Avoid both diltiazem and verapamil; use beta-blockers instead 3
• Patients with obstructive HCM and severe symptoms: Both verapamil and diltiazem may be harmful 3

Monitoring After Switching

• Blood pressure and heart rate within 1-2 weeks
• Symptoms of bradycardia or hypotension
• If transitioning to beta-blockers, monitor for bronchospasm in susceptible patients

Remember that when switching from diltiazem ER to verapamil ER, the total daily dose in milligrams can generally remain the same 1, making this a convenient and effective alternative that maintains similar pharmacological properties.