Nifedipine Dosing and Treatment Protocol
For hypertension and angina, use nifedipine extended-release 30-60 mg once daily on an empty stomach, with titration over 7-14 days; avoid immediate-release formulations except in hypertensive emergencies where oral methyldopa or nifedipine is recommended for severe hypertension. 1, 2
Standard Dosing for Hypertension
- Start with 30 mg once daily of extended-release formulation, taken on an empty stomach 1
- Titrate upward over 7-14 days based on blood pressure response and tolerability 1
- Usual maintenance dose is 30-60 mg once daily, with a maximum of 90 mg daily (doses above 90 mg are not recommended) 1
- Swallow tablets whole—do not bite, chew, or divide the extended-release formulation 1
The extended-release formulation provides consistent 24-hour blood pressure control with once-daily dosing, unlike immediate-release which requires multiple daily doses and carries safety concerns 3.
Dosing for Angina Pectoris
Extended-Release Formulation (Preferred)
- Use 30-180 mg daily of slow-release nifedipine for stable angina 3
- Once-daily dosing is typically sufficient for angina management 3
Immediate-Release Formulation (Avoid as Monotherapy)
- 30-90 mg daily divided into multiple doses if immediate-release must be used 3
- Never use immediate-release nifedipine for unstable angina or NSTEMI without concomitant beta-blockade due to increased risk of adverse cardiovascular events 3, 4
- Immediate-release nifedipine is contraindicated in recent myocardial infarction or unstable angina 4
Hypertensive Emergencies
In severe hypertension, oral nifedipine or methyldopa is recommended as first-line, with intravenous hydralazine as second-line 2
For hypertensive emergencies requiring parenteral therapy:
- Nicardipine IV: Start 5 mg/h, increase by 2.5 mg/h every 5 minutes to maximum 15 mg/h 2
- Clevidipine IV: Start 1-2 mg/h, double every 90 seconds until approaching target, then increase more gradually; maximum 32 mg/h for up to 72 hours 2
Blood Pressure Reduction Targets in Emergencies
- Without compelling conditions: Reduce SBP by no more than 25% in first hour, then to 160/100 mmHg over 2-6 hours, then cautiously to normal over 24-48 hours 2
- With aortic dissection: Reduce SBP to <120 mmHg in first hour 2
- With severe preeclampsia/eclampsia or pheochromocytoma: Reduce SBP to <140 mmHg in first hour 2
Resistant Hypertension
Nifedipine extended-release is among the most studied agents for resistant hypertension and should be considered when initial combination therapy fails 3
- Long-acting nifedipine may have slightly greater antihypertensive effects than amlodipine but causes more peripheral edema 3
- Combine with thiazide diuretic or RAS blocker as part of initial combination therapy 2
- If resistant hypertension persists, add spironolactone 25-50 mg daily to existing regimen 2
Critical Safety Considerations
Formulation-Specific Warnings
- Avoid grapefruit juice with nifedipine as it significantly alters drug metabolism 1
- Immediate-release nifedipine carries substantial risks: abrupt hypotension leading to neurological and cardiac events, increased coronary events in unstable angina 4
- Extended-release formulation is strongly preferred for all chronic indications due to superior safety profile 3
Discontinuation Protocol
- Taper gradually under close supervision rather than abrupt cessation 1
Common Dose-Related Side Effects
- Peripheral edema, headache, flushing, dizziness, hypotension, nausea, and constipation are related to vasodilatory action 3
- These effects are generally more pronounced with immediate-release formulations 3
Special Populations
Pediatric Pulmonary Hypertension
- Start 0.1-0.2 mg/kg orally three times daily 3
- Dose range: 2-3 mg/kg/day, maximum 180 mg/day 3
- Only 10-15% of pulmonary arterial hypertension patients respond to calcium channel blockers 3