Nifedipine Dosing Recommendations
For hypertension and angina, use nifedipine extended-release (XL/GITS) formulation at 30-60 mg once daily as the standard maintenance dose, with a starting dose of 30 mg and maximum of 180 mg daily; avoid immediate-release formulations unless combined with beta-blockade. 1, 2
Standard Dosing for Adults
Hypertension
- Start with 30 mg once daily of extended-release formulation on an empty stomach 2
- Titrate over 7-14 days based on blood pressure response 2
- Usual maintenance dose: 30-60 mg once daily 1, 2
- Maximum dose: 180 mg daily for extended-release formulation 3
- Doses above 90 mg daily are not routinely recommended unless treating resistant hypertension 2
Angina Pectoris
- Extended-release formulation: 30-180 mg once daily 1
- Immediate-release formulation (if used): 30-90 mg daily divided into multiple doses, but only with concomitant beta-blockade 1, 3
- The extended-release formulation is strongly preferred due to superior safety profile 1
Critical Safety Considerations
Formulation-Specific Warnings
- Immediate-release nifedipine should NOT be used for unstable angina/NSTEMI except with concomitant beta-blockade due to increased risk of adverse cardiovascular events 1, 3
- The American College of Cardiology specifically warns against immediate-release formulations without beta-blocker coverage 1, 3
- Extended-release tablets must be swallowed whole, never bitten or divided 2
Administration Guidelines
- Administer on an empty stomach 2
- Avoid grapefruit juice co-administration as it significantly affects nifedipine metabolism 2
- When discontinuing, taper gradually under close supervision rather than abrupt cessation 2
Special Populations
Pediatric Dosing
- Starting dose: 0.25-0.5 mg/kg per day 3
- For pulmonary hypertension: 0.1-0.2 mg/kg orally 3 times daily 1
- Maximum pediatric dose: 3 mg/kg/day up to 120 mg/day 3
- Dose range for pulmonary hypertension: 2-3 mg/kg/day with adult maximum of 180 mg/day 1
Resistant Hypertension
- Extended-release nifedipine is among the most studied agents for resistant hypertension 1
- May require higher doses within the 90-180 mg daily range 1
- Some evidence suggests nifedipine may have slightly greater antihypertensive effect than amlodipine but with more edema 1
Pulmonary Hypertension
- High doses (120-240 mg daily) may be required in vasoreactive patients 3
- Only 10-15% of pulmonary arterial hypertension patients will have positive acute vasoreactive response 1
Common Pitfalls and Management
Dose-Dependent Side Effects
- Peripheral edema, hypotension, dizziness, flushing, headache, nausea, and constipation are common and dose-related 1, 3
- Edema is particularly problematic and dose-dependent 4
- Consider using lowest effective dose to minimize edema 4
Managing Edema
- Switch to non-dihydropyridine calcium channel blockers (verapamil or diltiazem) if edema becomes problematic 4
- In patients with glomerular disease, nifedipine may exacerbate edema and increase proteinuria 4
- Diabetic patients are particularly susceptible to developing edema and require careful monitoring 4
Pharmacokinetic Advantages of Extended-Release
- Extended-release formulation maintains therapeutic levels for 24 hours with once-daily dosing 1
- Provides more consistent plasma concentrations compared to immediate-release 1
- Better adherence with once-daily dosing versus multiple daily doses 1
- 120 mg XL once daily is strongly preferred over divided doses of 120 mg immediate-release liquid 1
Clinical Pearls
- Nifedipine is a dihydropyridine calcium channel blocker causing primarily peripheral arterial dilation with minimal AV or sinus node effects 1
- For patients unable to swallow tablets, consider alternative calcium channel blockers in liquid formulations rather than immediate-release nifedipine liquid 1
- Tachycardia may occur, particularly with immediate-release formulations 3
- The blood pressure reduction is inversely correlated with pretreatment blood pressure levels 5