Maximum Doses of Calcium Channel Blockers (CCBs)
The maximum doses of calcium channel blockers vary by specific agent, with amlodipine having a maximum dose of 10 mg daily, nifedipine extended-release 90 mg daily, and verapamil up to 30 mg total for acute use in arrhythmias. 1, 2, 3
Maximum Doses by CCB Class
Dihydropyridine CCBs
- Amlodipine: Maximum dose 10 mg once daily for adults 1
- Nifedipine extended-release: Maximum recommended dose 90 mg once daily 2
- Amlodipine (pediatric): Maximum dose 5 mg daily for children ages 6-17 years 1
Non-dihydropyridine CCBs
- Verapamil (acute IV use): Maximum total dose of 20-30 mg for treatment of arrhythmias 3
- Diltiazem (pediatric): Maximum dose 360 mg/day orally 3
- Amlodipine (pediatric): Maximum dose 10 mg/day orally 3
Special Population Considerations
Hepatic Impairment
- For patients with hepatic insufficiency, lower starting doses are recommended (e.g., amlodipine 2.5 mg daily) 1
- Elderly or fragile patients should also be started on lower doses (2.5 mg daily for amlodipine) 1
Cardiovascular Conditions
- For coronary artery disease, the recommended dose range for amlodipine is 5-10 mg once daily, with most patients requiring 10 mg 1
- For angina, amlodipine dosing ranges from 5-10 mg daily, with lower doses suggested for elderly and hepatic insufficiency patients 1
Titration Guidelines
- For amlodipine, titration should generally proceed over 7-14 days between dose adjustments 1
- For nifedipine extended-release, titration should proceed over a 7-14 day period starting with 30 mg once daily 2
- More rapid titration may be clinically warranted for amlodipine if the patient is assessed frequently 1
Safety Considerations
- High doses of dihydropyridine CCBs often cause peripheral edema, headache, flushing, and tachycardia 4
- High doses of verapamil can cause constipation 4
- CCBs should be used with caution in patients with left ventricular dysfunction 5
- Non-dihydropyridine CCBs (verapamil, diltiazem) have stronger negative chronotropic and inotropic effects than dihydropyridines 4, 5
- Avoid CCBs in patients with heart failure and pre-excited atrial fibrillation or flutter 3
Administration Considerations
- Nifedipine extended-release tablets should be swallowed whole, not bitten or divided 2
- Nifedipine should be administered on an empty stomach 2
- Co-administration of nifedipine with grapefruit juice should be avoided 2
- Amlodipine can be administered at the most convenient time of day for the patient to improve adherence 6
Remember that dosing should be adjusted according to blood pressure goals and individual patient response, with careful monitoring for side effects, particularly at higher doses 1, 2.