What is the recommended dose of Nifedipine (Calcium Channel Blocker) for treating hypertension and angina?

Nifedipine Dosing for Hypertension and Angina

For hypertension, use extended-release nifedipine 30-90 mg once daily; for angina, use 30-180 mg daily of slow-release formulation, and avoid immediate-release capsules entirely as they should no longer be prescribed due to safety concerns. 1, 2

Hypertension Dosing

• Extended-release (XL) formulation: 30-180 mg once daily is the preferred approach, providing consistent 24-hour blood pressure control with once-daily dosing 2
• Start at 30 mg daily and titrate upward based on response, allowing at least 4 weeks between dose adjustments to observe full therapeutic effect 1
• The 20 mg dose may be sufficient for elderly patients or those with lower body weight who are already controlled on higher doses, though 30 mg remains the standard starting dose 3
• Extended-release formulations are strongly preferred over immediate-release due to superior safety profile and better adherence 2

Angina Dosing

• Slow-release formulation: 30-180 mg daily is recommended for stable angina 2
• Immediate-release nifedipine (30-90 mg daily in divided doses) should only be used with concomitant beta-blockade and never for unstable angina or NSTEMI due to increased adverse cardiovascular events 2, 4
• The American College of Cardiology explicitly warns against using immediate-release nifedipine without beta-blocker coverage 2

Critical Safety Considerations

• Nifedipine capsules (immediate-release) should no longer be prescribed - this is a firm recommendation from the British Hypertension Society due to safety concerns with rapid blood pressure drops 1
• Sublingual or intravenous administration can cause precipitous blood pressure reduction leading to myocardial infarction or fetal distress in pregnancy 1, 4
• When combined with intravenous magnesium (as in pregnancy), myocardial depression may occur 1

Combination Therapy Approach

• Most hypertensive patients require combination therapy to achieve optimal control 1
• Nifedipine combines effectively with beta-blockers (like atenolol) or ACE inhibitors, as drugs from different classes have additive blood pressure effects 1, 5
• Use submaximal doses of two drugs rather than maximal doses of a single drug to achieve larger blood pressure responses with fewer side effects 1
• For resistant hypertension, extended-release nifedipine is among the most studied and effective agents, though it may cause slightly more edema than amlodipine 2

Common Pitfalls to Avoid

• Never use immediate-release liquid formulations - if a patient cannot swallow tablets, consider alternative calcium channel blockers available in liquid form rather than immediate-release nifedipine 2
• Do not increase diuretic doses beyond manufacturer recommendations; instead, add drugs stepwise for severe or complicated hypertension 1
• Monitor for dose-related vasodilatory side effects including peripheral edema, headache, flushing, dizziness, hypotension, nausea, and constipation 2

Special Populations

• Pregnancy: Methyldopa remains first-line; nifedipine can be used but avoid rapid administration routes and combination with IV magnesium 1
• Elderly with isolated systolic hypertension: Dihydropyridine calcium antagonists like nifedipine are particularly indicated 1
• Pediatric pulmonary hypertension: Start 0.1-0.2 mg/kg orally three times daily, maximum 180 mg/day 2