Nifedipine Dosing and Treatment Protocol
Primary Recommendation
For hypertension and angina, use extended-release nifedipine at 30-60 mg once daily on an empty stomach, starting at 30 mg and titrating over 7-14 days; avoid immediate-release formulations unless the patient is already on beta-blocker therapy. 1, 2
Dosing by Indication
Hypertension
- Start: 30 mg once daily of extended-release formulation 1
- Maintenance: 30-60 mg once daily 2, 1
- Maximum: 90 mg daily (doses above this are not recommended) 1
- Titration: Increase over 7-14 days based on blood pressure response 1
- Administration: Once daily on an empty stomach; tablets must be swallowed whole, never crushed or divided 1
Chronic Stable Angina
- Extended-release: 30-180 mg once daily 2
- Immediate-release: 30-90 mg daily in divided doses (only if on concurrent beta-blocker) 3, 2
- Key caveat: The American College of Cardiology emphasizes that immediate-release nifedipine must be avoided in unstable angina/NSTEMI unless the patient is already receiving beta-blockade due to increased adverse cardiovascular events 3, 2
Treatment Algorithm for Hypertension with Comorbidities
Hypertension + Chronic Stable Angina
- First-line regimen: Beta-blocker + ACE inhibitor (or ARB if diabetic/LV dysfunction present) + thiazide diuretic 3
- If angina or BP uncontrolled: Add long-acting dihydropyridine CCB (nifedipine extended-release) to the basic regimen 3
- If beta-blocker contraindicated: Substitute non-dihydropyridine CCB (diltiazem or verapamil), but avoid if LV dysfunction present 3
- Target BP: <130/80 mm Hg (consider <120/80 mm Hg if ventricular dysfunction present) 3
Resistant Hypertension
- Nifedipine extended-release is among the most studied agents for resistant hypertension 2
- Some evidence suggests nifedipine may have slightly greater antihypertensive effects than amlodipine but causes more peripheral edema 2
Critical Safety Considerations
Absolute Contraindications to Immediate-Release Nifedipine
- Never use immediate-release nifedipine in acute coronary syndromes without concurrent beta-blockade 3, 2
- The Holland Interuniversity Nifedipine/metoprolol Trial (HINT) was stopped early due to harm with nifedipine monotherapy in unstable angina 3
Cautions with Non-Dihydropyridine CCBs
- Avoid combining beta-blockers with non-dihydropyridine CCBs (diltiazem/verapamil) due to increased risk of bradyarrhythmias and heart failure 3
- Verapamil and diltiazem should be avoided in patients with pulmonary edema or severe LV dysfunction 3
Blood Pressure Lowering Precautions
- Lower BP slowly in patients with coronary artery disease 3
- Exercise caution when diastolic BP falls below 60 mm Hg, as this may precipitate myocardial ischemia 3
- In elderly patients with wide pulse pressures, lowering systolic BP may cause very low diastolic values requiring careful monitoring 3
Common Side Effects
Dose-related vasodilatory effects include: hypotension, dizziness, flushing, nausea, constipation, headache, and peripheral edema 3, 2
- These effects are generally mild to moderate and often diminish with continued treatment 4
- Extended-release formulations are better tolerated than immediate-release, particularly regarding reflex tachycardia 4
Drug Interactions
Avoid co-administration with grapefruit juice, as it significantly affects nifedipine metabolism 1
Discontinuation Protocol
If discontinuation is necessary, decrease dosage gradually under close physician supervision rather than abrupt cessation 1
Formulation Comparison
Extended-Release vs Immediate-Release
- Extended-release provides 24-hour therapeutic levels with once-daily dosing 2
- Immediate-release requires multiple daily doses and carries higher cardiovascular risk 2
- For patients requiring 120 mg daily, one extended-release tablet is strongly preferred over divided doses of immediate-release due to improved safety, adherence, and consistent plasma concentrations 2
- For patients unable to swallow tablets, consider alternative CCBs available in liquid formulations rather than immediate-release nifedipine liquid 2