What are the alternatives to diltiazem (Cardizem) ER 120?

Alternatives to Diltiazem ER 120mg

For patients requiring an alternative to diltiazem ER 120mg, beta-blockers are the preferred first-line substitute for most indications, particularly in patients with hypertension and stable angina, unless contraindicated. 1

Primary Alternatives Based on Clinical Indication

For Hypertension and Stable Angina

• Beta-blockers represent the optimal alternative, as they are recommended as first-line therapy for hypertension with stable angina and provide both blood pressure control and anti-ischemic effects 1
• ACE inhibitors or ARBs should be added or substituted if beta-blockers are contraindicated or not tolerated, particularly in patients with diabetes, chronic kidney disease, or high cardiovascular risk 1
• Long-acting dihydropyridine calcium channel blockers (amlodipine, felodipine) can be used as alternatives, though they lack the heart rate-lowering effects of diltiazem 1, 2

For Rate Control in Atrial Fibrillation

• Beta-blockers are the preferred alternative for rate control in atrial fibrillation, especially if heart failure with reduced ejection fraction is present, as they avoid the negative inotropic effects of non-dihydropyridine calcium channel blockers 1
• Verapamil can substitute for diltiazem using a 1:1 initial dose conversion (120mg verapamil for 120mg diltiazem), though verapamil has more extensive drug interactions, particularly with P-glycoprotein substrates like direct oral anticoagulants 1, 3
• Combination therapy with beta-blocker plus diltiazem or verapamil may be considered in refractory cases where single-agent therapy fails to adequately control heart rate, though this requires careful monitoring for excessive bradycardia 1

Specific Alternative Recommendations by Clinical Scenario

When Beta-Blockers Are Contraindicated

• Verapamil is the most direct substitute, using equivalent dosing starting at 120mg daily, but avoid in patients with left ventricular dysfunction, bradycardia, or AV block 1, 3
• Long-acting dihydropyridines (amlodipine 5-10mg daily) can be used for hypertension but do not provide rate control or the same anti-ischemic benefits 1

For Patients with Heart Failure or LV Dysfunction

• Beta-blockers are strongly preferred as they improve outcomes in heart failure, whereas both diltiazem and verapamil are contraindicated in decompensated heart failure or severe LV dysfunction 1
• ACE inhibitors or ARBs plus beta-blockers form the foundation of therapy in this population 1

For Vasospastic Angina

• Any calcium channel blocker is appropriate, including switching to verapamil (120mg daily) or a dihydropyridine like amlodipine (5-10mg daily), as all classes effectively prevent coronary vasospasm 1

Critical Considerations When Switching

Drug Interaction Differences

• Verapamil has more extensive drug interactions than diltiazem, particularly inhibiting P-glycoprotein, which increases levels of dabigatran, edoxaban, rivaroxaban, and other medications 1, 3
• Beta-blockers generally have fewer drug interactions than non-dihydropyridine calcium channel blockers 1

Monitoring After Transition

• Monitor blood pressure and heart rate for 1-2 weeks after switching from diltiazem to ensure adequate control and detect any adverse effects 4
• Assess for return of symptoms including angina, palpitations, or elevated blood pressure 4
• Watch for bradycardia or AV block when switching to verapamil or beta-blockers, especially in patients with baseline conduction abnormalities 3

Common Pitfalls to Avoid

• Do not combine beta-blockers with non-dihydropyridine calcium channel blockers (verapamil or diltiazem) routinely, as this significantly increases risk of bradycardia, heart block, and heart failure 1, 3
• Avoid verapamil or diltiazem alternatives in patients with LV dysfunction, as both have negative inotropic effects; use beta-blockers instead 1
• Do not use short-acting nifedipine as an alternative, as it causes reflex tachycardia and can worsen myocardial ischemia 1
• Diltiazem does not require tapering when discontinuing, unlike beta-blockers which should be tapered to avoid rebound phenomena 4

Side Effect Profile Differences

• Dihydropyridines cause more peripheral edema (especially in women) compared to diltiazem, verapamil, or beta-blockers 2
• Verapamil commonly causes constipation, which may be problematic in certain patients 2
• Beta-blockers may cause fatigue, bronchospasm (in patients with reactive airway disease), and mask hypoglycemia symptoms in diabetics 1