What are the guideline-recommended indications for nifedipine (Calcium Channel Blocker), and are there any concurrent or sequential medications required for effective treatment?

From the Guidelines

Nifedipine is recommended for ischemic symptoms when beta blockers are not successful, are contraindicated, or cause unacceptable side effects, and it should be used with caution, particularly in patients with certain cardiovascular conditions, such as left ventricular dysfunction or cardiogenic shock 1.

Guideline-Recommended Indications for Nifedipine

• Ischemic symptoms: Nifedipine can be used to control ongoing or recurring ischemia-related symptoms in patients who are already receiving adequate doses of nitrates and beta blockers, or in patients who are unable to tolerate adequate doses of one or both of these agents 1.
• Variant angina: Nifedipine can be used to manage variant angina, which is a type of angina caused by coronary artery spasm 1.
• Hypertension: Nifedipine can be used to manage hypertension in patients with recurrent unstable angina (UA) 1.

Concurrent or Sequential Medications Required for Effective Treatment

• Beta blockers: Nifedipine should be used with caution in patients who are not receiving beta blockers, as the combination of nifedipine and beta blockers can increase the risk of adverse effects, such as hypotension and bradycardia 1.
• Nitrates: Nifedipine can be used in combination with nitrates to control ischemic symptoms, but the combination should be used with caution, particularly in patients with certain cardiovascular conditions, such as left ventricular dysfunction or cardiogenic shock 1.

Important Considerations

• Contraindications: Nifedipine is contraindicated in patients with certain cardiovascular conditions, such as left ventricular dysfunction, cardiogenic shock, or second- or third-degree atrioventricular block without a cardiac pacemaker 1.
• Dosing: The usual dose of nifedipine is 30 to 90 mg daily orally, and it should be titrated to achieve the desired therapeutic effect while minimizing adverse effects 1.
• Monitoring: Patients receiving nifedipine should be monitored closely for adverse effects, such as hypotension, bradycardia, and edema, and for signs of ischemic symptoms, such as chest pain or shortness of breath 1.

From the FDA Drug Label

Nifedipine extended-release tablets, USP are indicated for the treatment of hypertension. It may be used alone or in combination with other antihypertensive agents. The guideline-recommended indication for nifedipine is the treatment of hypertension.

• Nifedipine may be used alone or in combination with other antihypertensive agents.
• There are no specific concurrent or sequential medications required for effective treatment, but careful consideration and monitoring are necessary when co-administering nifedipine with other medications, such as:
  • CYP3A inhibitors (e.g., ketoconazole, fluconazole) which may increase nifedipine exposure
  • Strong CYP3A inducers (e.g., rifampin) which may reduce nifedipine bioavailability and efficacy
  • Antiarrhythmics (e.g., quinidine) which may increase nifedipine exposure
  • Calcium Channel Blockers (e.g., diltiazem, verapamil) which may increase nifedipine exposure
  • ACE Inhibitors (e.g., benazepril) which may have a hypotensive effect when co-administered with nifedipine
  • Beta-blockers which may increase the likelihood of congestive heart failure, severe hypotension, or exacerbation of angina in patients with cardiovascular disease 2, 2

From the Research

Guideline-Recommended Indications for Nifedipine

• Nifedipine is indicated for the treatment of:
  • Vasospastic and chronic stable angina 3
  • Malignant hypertension 3, 4, 5
  • Raynaud's phenomenon 3, 6
  • Hypertensive urgencies and emergencies 4, 5
  • Mild to moderate hypertension 6, 7
  • Stable and variant angina pectoris 6
  • Peripheral vascular disorders 6
  • Hypertension in pregnancy 6
  • Silent myocardial ischaemia 6

Concurrent or Sequential Medications

• Sustained release nifedipine formulations can be used in combination with other medications, such as:
  • Atenolol 50 mg in a fixed combination capsule 6
• Modified-release nifedipine formulations are preferred due to their gradual increase in plasma nifedipine concentration, which avoids baroreflex sympathetic activation 7
• Nifedipine GITS (gastrointestinal therapeutic system) has been shown to reduce the need for coronary procedures in patients with coronary artery disease 7
• Nifedipine retard has been shown to have beneficial effects on the overall incidence of major cardiovascular events in patients with hypertension and concurrent hypertension and coronary artery disease 7