What are the parameters to hold Cardizem (Diltiazem) for hypotension?

Parameters for Holding Diltiazem (Cardizem) Due to Hypotension

Diltiazem should be held if systolic blood pressure is less than 90 mmHg, as this is a contraindication according to FDA labeling. 1

Blood Pressure Parameters

• Hold diltiazem if systolic blood pressure is less than 90 mmHg (hypotension) 1
• Use with caution in patients with borderline blood pressure (90-100 mmHg systolic) due to risk of significant hypotension 2
• Monitor blood pressure closely after administration, as hypotension is the most common adverse effect 2
• Consider holding diltiazem in patients with decompensated heart failure, as it may worsen hypotension in these patients 3

Cardiac Parameters

• Hold diltiazem in patients with:
  • Sick sinus syndrome (unless patient has functioning ventricular pacemaker) 1
  • Second or third-degree AV block (unless patient has functioning ventricular pacemaker) 1
  • Acute myocardial infarction with pulmonary congestion 1
  • Decompensated systolic heart failure or severe left ventricular dysfunction 3, 2
  • Cardiogenic shock 3

Management of Diltiazem-Induced Hypotension

If hypotension occurs after diltiazem administration:

• Administer vasopressors (e.g., dopamine or norepinephrine) 1
• Consider intravenous fluids if not contraindicated 1
• For severe cases, calcium administration may help reverse calcium channel blocker effects:
  • 1 g calcium chloride or 3 g calcium gluconate over 5 minutes, repeated every 10-20 minutes as necessary 1
  • Calcium gluconate can also be administered as continuous infusion at 2 g per hour 1

Dosing Considerations to Minimize Hypotension Risk

• Consider using lower initial doses of diltiazem (≤0.2 mg/kg IV) in patients at risk for hypotension, as this has been shown to be as effective as standard dosing with lower hypotension risk 4
• For IV administration, standard dosing is 0.25 mg/kg over 2 minutes, with maintenance infusion at 5-15 mg/hour 3
• For oral administration, initial doses typically start at 120 mg daily, with maximum maintenance doses of 360 mg daily 2

Special Populations at Higher Risk

• Elderly patients are more susceptible to hypotension with diltiazem 2
• Patients with hepatic or renal dysfunction may have altered metabolism of diltiazem, increasing hypotension risk 3
• Patients taking other medications with SA and/or AV nodal-blocking properties have increased risk of bradycardia and hypotension 3
• Patients with Wolff-Parkinson-White syndrome with atrial fibrillation/flutter should not receive diltiazem 3

Drug Interactions That May Worsen Hypotension

• Use caution when combining diltiazem with beta-blockers due to increased risk of bradyarrhythmias and heart failure 3, 5
• Diltiazem is a CYP3A4 substrate and moderate inhibitor; use caution with medications metabolized through this pathway 3, 2
• Avoid routine use with other medications that can cause hypotension 2