What is the recommended dosage and treatment guidelines for nifedipine (calcium channel blocker) for hypertension?

Nifedipine Dosing for Hypertension

For hypertension treatment, use nifedipine extended-release 30-60 mg once daily on an empty stomach, starting at 30 mg and titrating over 7-14 days; immediate-release nifedipine capsules should never be used due to serious cardiovascular risks including myocardial infarction and stroke. 1, 2

Formulation Selection

• Only extended-release (XL) formulations are acceptable for hypertension management, dosed at 30-180 mg once daily 3, 1
• Immediate-release nifedipine capsules are contraindicated and no longer considered acceptable for any hypertensive treatment due to documented cardiovascular events including myocardial infarction, acute hypotension with ECG changes, and precipitous drops causing renal, cerebral, or coronary ischemia 2, 4
• The extended-release formulation provides consistent 24-hour plasma concentrations, while immediate-release requires multiple daily dosing with unpredictable blood pressure drops 3

Dosing Protocol

Starting dose: 30 mg once daily on an empty stomach 1

Titration schedule:

• Increase dose over 7-14 day intervals based on therapeutic response 1
• Usual maintenance dose is 30-60 mg once daily 1
• Maximum recommended dose is 90 mg daily; doses above this are not recommended 1

Administration specifics:

• Tablets must be swallowed whole, never bitten or divided 1
• Take on an empty stomach for optimal absorption 1
• Avoid grapefruit juice co-administration as it significantly alters pharmacokinetics 1

Role in Treatment Guidelines

Long-acting dihydropyridine calcium channel blockers (including nifedipine XL) are recommended as first-line agents for hypertension by the WHO, alongside thiazides, ACE inhibitors, and ARBs 4

Combination therapy approach:

• Most hypertensive patients require combination therapy to achieve blood pressure control 4
• Nifedipine can be combined with drugs from other classes (thiazides, ACE inhibitors, ARBs) preferably as single-pill combinations 4
• Submaximal doses of two drugs produce larger blood pressure responses with fewer side effects than maximal doses of single agents 4

Blood Pressure Targets

• Standard target: <140/90 mm Hg for patients without comorbidities 4
• Patients with cardiovascular disease: <130 mm Hg systolic 4
• High-risk patients (diabetes, chronic kidney disease, high CVD risk): <130 mm Hg systolic 4

Specific Clinical Indications

Compelling indication: Isolated systolic hypertension in elderly patients 4

Resistant hypertension: Nifedipine extended-release is among the most studied agents for resistant hypertension, though it may cause slightly more edema than amlodipine despite potentially greater antihypertensive effect 3

Critical Safety Warnings

Absolute contraindications for immediate-release nifedipine:

• Non-ST-elevation acute coronary syndrome without beta-blocker therapy (Class III: Harm recommendation) 2
• Hypertensive emergencies or urgencies 2
• Any patient with coronary artery disease, prior stroke, or arrhythmia history without concomitant beta-blockade 2, 5

Common side effects (dose-related, due to vasodilatory action):

• Peripheral edema 3
• Headache 3
• Flushing 3
• Dizziness 3
• Hypotension 3

Discontinuation Protocol

If discontinuation becomes necessary, decrease dosage gradually under close physician supervision rather than abrupt cessation 1

Follow-Up Schedule

• Monthly follow-up after initiation or dose changes until target blood pressure achieved 4
• Every 3-5 months for patients with controlled blood pressure 4
• Allow at least 4 weeks to observe full response before dose adjustments unless urgent blood pressure lowering is required 4