What can replace Nisoldipine (Nifedipine derivative) Extended Release (ER) for hypertension management?

Replacing Nisoldipine ER for Hypertension Management

Amlodipine is the most appropriate replacement for Nisoldipine ER in the management of hypertension. 1

Rationale for Recommendation

• Nisoldipine is a dihydropyridine calcium channel blocker (CCB) used for hypertension management 1
• Amlodipine is the preferred alternative as it:
  • Belongs to the same dihydropyridine CCB class as nisoldipine 1
  • Has a similar mechanism of action with comparable efficacy 1
  • Has a long half-life allowing for once-daily dosing (similar to Nisoldipine ER) 1, 2
  • Has extensive clinical evidence supporting its use in hypertension 1

Dosing Conversion Guidelines

• For patients on Nisoldipine ER 10-20 mg daily, start with Amlodipine 5 mg once daily 1, 3
• For patients on Nisoldipine ER 30-40 mg daily, start with Amlodipine 10 mg once daily 3
• Monitor blood pressure after conversion and adjust dose as needed 3
• Amlodipine's dosing range is 2.5-10 mg once daily 1

Other Potential Alternatives

Other Dihydropyridine CCBs

• Nifedipine long-acting/extended-release (30-60 mg once daily) is another option but requires careful product selection to ensure extended-release properties 1, 4
• Felodipine (2.5-10 mg once daily) can also be considered 1

Non-dihydropyridine CCBs

• Diltiazem ER (120-360 mg once daily) or Verapamil SR (120-360 mg daily) could be alternatives, but they have different pharmacological profiles with more pronounced effects on heart rate and cardiac conduction 1
• These should be avoided in patients with heart failure with reduced ejection fraction 1

Important Considerations

• Avoid switching to short-acting CCBs like immediate-release nifedipine due to risk of reflex tachycardia and unpredictable blood pressure fluctuations 1, 5
• If CCBs are not tolerated or contraindicated, consider other antihypertensive classes based on the 2017 ACC/AHA guidelines 1:
  • Thiazide-type diuretics (chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide) 1
  • ACE inhibitors (e.g., lisinopril 10-40 mg daily) 1
  • ARBs (e.g., losartan 50-100 mg daily) 1

Monitoring After Medication Change

• Check blood pressure within 1-2 weeks after switching medications 3
• Monitor for common side effects of amlodipine including peripheral edema, headache, and flushing 2, 4
• Amlodipine is generally better tolerated than nifedipine with fewer side effects 2
• Ensure continued avoidance of medications that can exacerbate hypertension, such as decongestants containing pseudoephedrine or phenylephrine 6

Special Populations

• In patients with heart failure, amlodipine is preferred over other CCBs 1
• In elderly patients, consider starting with a lower dose (2.5 mg) of amlodipine 1
• For patients with resistant hypertension, adding a mineralocorticoid receptor antagonist may be beneficial if changing to amlodipine does not provide adequate control 1