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Use Cautiously in: Severe hepatic impairment (pdose recommended); Geri:p
diltiazem (dil-tye-a-zem)
Cardizem, Cardizem CD, Cardizem LA, Cartia XT, Dilacor XR, Taztia XT, Tiazac
Classification
Therapeutic: antianginals, antiarrhythmics (class IV), antihypertensives
Pharmacologic: calcium channel blockers
Pregnancy Category C
Indications
Hypertension. Angina pectoris and vasospastic (Prinzmetal’s) angina. Supraventricular tachyarrhythmias and rapid ventricular rates in atrial flutter or fibrillation.
Action
Inhibits transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction.
Therapeutic Effects: Systemic vasodilation resulting in decreased BP. Coronary
vasodilation resulting in decreased frequency and severity of attacks of angina. Reduction of ventricular rate in atrial fibrillation or flutter.
Pharmacokinetics
Absorption: Well absorbed, but rapidly metabolized after oral administration.
Distribution: Unknown.
Protein Binding: 70– 80%.
Metabolism and Excretion: Mostly metabolized by the liver (CYP3A4 enzyme
system).
Half-life: 3.5– 9 hr.
TIME/ACTION PROFILE
ROUTE
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ONSET
PEAK
PO
30 min
2–3 hr
PO–SR
unknown
unknown
PO–CD, XR, LA
unknown
14 days†
IV
2–5 min
2–4 hr
†Maximum antihypertensive effect with chronic therapy
DURATION
6–8 hr
12 hr
up to 24 hr
unknown
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Sick sinus syndrome; 2nd- or 3rd-degree
AV block (unless an artificial pacemaker is in place); Systolic BP ⬍90 mm Hg; Recent
MI or pulmonary congestion; Concurrent use of rifampin.
⫽ Canadian drug name.
⫽ Genetic Implication.
dose; slower IV infusion rate recommended;qrisk of hypotension; consider age-related decrease in body mass,phepatic/renal/cardiac function, concurrent drug therapy and other disease states); Severe renal impairment; Serious ventricular arrhythmias or HF; OB, Lactation, Pedi: Safety not established.
Adverse Reactions/Side Effects
CNS: abnormal dreams, anxiety, confusion, dizziness, drowsiness, headache, nervousness, psychiatric disturbances, weakness. EENT: blurred vision, disturbed equilibrium, epistaxis, tinnitus. Resp: cough, dyspnea. CV: ARRHYTHMIAS, HF, peripheral edema, bradycardia, chest pain, hypotension, palpitations, syncope, tachycardia.
GI:qliver enzymes, anorexia, constipation, diarrhea, dry mouth, dysgeusia, dyspepsia, nausea, vomiting. GU: dysuria, nocturia, polyuria, sexual dysfunction, urinary
frequency. Derm: STEVENS-JOHNSON SYNDROME, dermatitis, erythema multiforme,
flushing, sweating, photosensitivity, pruritus/urticaria, rash. Endo: gynecomastia,
hyperglycemia. Hemat: anemia, leukopenia, thrombocytopenia. Metab: weight
gain. MS: joint stiffness, muscle cramps. Neuro: paresthesia, tremor. Misc: gingival hyperplasia.
Interactions
Drug-Drug: q hypotension may occur when used with fentanyl, other antihypertensives, nitrates, acute ingestion of alcohol, or quinidine. Antihypertensive effects may bepby NSAIDs. Mayqdigoxin levels. Mayqlevels of and risk of
myopathy from simvastatin and lovastatin. Concurrent use with beta blockers,
clonidine, digoxin, disopyramide, or phenytoin may result in bradycardia, conduction defects, or HF. Phenobarbital and phenytoin mayqmetabolism andpeffectiveness. Maypmetabolism of andqrisk of toxicity from cyclosporine, quinidine, or carbamazepine. Cimetidine and ranitidineqlevels and effects. Mayq
orpthe effects of lithium or theophylline.
Drug-Food: Grapefruit juiceqlevels and effect.
Route/Dosage
PO (Adults): 30– 120 mg 3– 4 times daily or 60– 120 mg twice daily as SR capsules
or 180– 240 mg once daily as CD or XR capsules or LA tablets (up to 360 mg/day);
Concurrent simvastatin therapy— Diltiazem dose should not exceed 240 mg/day
and simvastatin dose should not exceed 10 mg/day.
IV (Adults): 0.25 mg/kg; may repeat in 15 min with a dose of 0.35 mg/kg. May follow with continuous infusion at 10 mg/hr (range 5– 15 mg/hr) for up to 24 hr.
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
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● PO: May be administered without regard to meals. May be administered with
NURSING IMPLICATIONS
Assessment
● Do not open, crush, break, or chew sustained-release capsules or tablets. Empty
meals if GI irritation becomes a problem.
● Monitor BP and pulse prior to therapy, during dose titration, and periodically dur●
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ing therapy. Monitor ECG periodically during prolonged therapy. May cause prolonged PR interval.
Monitor intake and output ratios and daily weight. Assess for signs of HF
(peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous
distention).
Monitor frequency of prescription refills to determine adherence.
Patients receiving digoxin concurrently with calcium channel blockers should
have routine serum digoxin levels checked and be monitored for signs and symptoms of digoxin toxicity.
Assess for rash periodically during therapy. May cause Stevens-Johnson
syndrome. Discontinue therapy if severe or if accompanied with fever,
general malaise, fatigue, muscle or joint aches, blisters, oral lesions,
conjunctivitis, hepatitis and/or eosinophilia.
Angina: Assess location, duration, intensity, and precipitating factors of patient’s
anginal pain.
Arrhythmias: Monitor ECG continuously during administration. Report
bradycardia or prolonged hypotension promptly. Emergency equipment
and medication should be available. Monitor BP and pulse before and
frequently during administration.
Lab Test Considerations: Total serum calcium concentrations are not affected
by calcium channel blockers.
Monitor serum potassium periodically. Hypokalemiaqthe risk of arrhythmias
and should be corrected.
Monitor renal and hepatic functions periodically during long-term therapy. May
causeqin hepatic enzymes after several days of therapy, which return to normal
on discontinuation of therapy.
Potential Nursing Diagnoses
Acute pain (Indications)
Decreased cardiac output (Adverse Reactions)
Implementation
● Do not confuse Tiazac (diltiazem) with Ziac (bisprolol/hydrochlorothi-
azide).
tablets that appear in stool are not significant. Crush and mix diltiazem with food
or fluids for patients having difficulty swallowing.
IV Administration
● Direct IV: Diluent: Administer bolus dose undiluted. Concentration: 5 mg/
mL. Rate: Administer over 2 min.
● Continuous Infusion: Diluent: Dilute 125 mg in 100 mL, 250 mg in 250 mL,
or 250 mg in 500 mL of 0.9% NaCl, D5W, or D5/0.45% NaCl. Infusion is stable for
24 hr at room temperature or if refrigerated. Concentration: 125 mg/125 mL
(1 mg/mL), 250 mg/300 mL (0.83 mg/mL), 250 mg/550 mL (0.45 mg/mL).
Rate: See Route/Dosage section. Titrate to patient’s heart rate and BP response.
● Y-Site Compatibility: albumin, alemtuzumab, alfentanil, amifostine, amikacin,
aminocaproic acid, amiodarone, amphotericin B colloidal, anidulafungin, argatroban, atracurium, azithromycin, aztreonam, bivalirudin, bleomycin, bumetanide, buprenorphine, busulfan, butorphanol, calcium chloride, calcium gluconate, carboplatin, carmustine, caspofungin, cefazolin, cefotaxime, cefotetan,
cefoxitin, ceftaroline, ceftazidime, ceftriaxone, cefuroxime, chlorpromazine, ciprofloxacin, cisatracurium, cisplatin, clindamycin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine,
dexrazoxane, digoxin, diphenhydramine, dobutamine, docetaxel, dolasetron, dopamine, doripenem, doxacurium, doxorubicin hydrochloride, doxycycline, droperidol, enalaprilat, ephendrine, epinephrine, epirubicin, eptifibatide, ertapenem, erythromycin lactobionate, esmolol, etoposide, etoposide phosphate,
famotidine, fenoldopam, fentanyl, fluconazole, fludarabine, foscarnet, fosphenytoin, gemcitabine, gentamicin, glycopyrrolate, granisetron, haloperidol, hetastarch, hydralazine, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin,
irinotecan, isoproterenol, labetalol, leucovorin calcium, levofloxacin, lidocaine,
linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, melphalan, meperidine, meropenem, metaraminol, methyldopate, metoclopramide,
metoprolol, metronidazole, midazolam, milrinone, mitoxantrone, morphine,
moxifloxacin, multivitamins, mycophenolate, nalbuphine, naloxone, nesiritide,
nicardipine, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pancuronium, pemetrexed, penicillin G potassium, pentamidine, phentolamine,
䉷 2015 F.A. Davis Company
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diltiazem
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phenylephrine, potassium acetate, potassium chloride, potassium phosphates,
prochlorperazine, promethazine, propranolol, quinupristin/dalfopristin, ranitidine, remifentanil, rocuronium, sodium acetate, streptozocin, succinylcholine,
sufentanil, tacrolimus, telavancin, teniposide, theophylline, thiotepa, ticarcillin/
clavulanate, tigecycline, tirofiban, tobramycin, trimethoprim/sulfamethoxazole,
vancomycin, vasopressin, vecuronium, verapamil, vinblastine, vincristine, vinorelbine, voriconazole, zidovudine, zoledronic acid.
● Y-Site Incompatibility: allopurinol, amphotericin B lipid complex, amphotericin B liposome, cefepime, chloramphenicol, dantrolene, diazepam, doxorubicin
liposomal, fluorouracil, furosemide, ganciclovir, ketorolac, methotrexate, micafungin, pantroprazole, pentobarbital, phenobarbital, phenytoin, piperacillin/tazobactam, rifampin, thiopental.
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Patient/Family Teaching
● Advise patient to take medication as directed at the same time each day, even if
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feeling well. Take missed doses as soon as possible unless almost time for next
dose; do not double doses. May need to be discontinued gradually.
Advise patient to avoid large amounts (6– 8 glasses of grapefruit juice/day) during
therapy.
Instruct patient on correct technique for monitoring pulse. Instruct patient to contact health care professional if heart rate is ⬍50 bpm.
Caution patient to change positions slowly to minimize orthostatic hypotension.
May cause drowsiness or dizziness. Advise patient to avoid driving or other activities requiring alertness until response to the medication is known.
Instruct patient on importance of maintaining good dental hygiene and seeing
dentist frequently for teeth cleaning to prevent tenderness, bleeding, and gingival
hyperplasia (gum enlargement).
Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to avoid concurrent use of alcohol or
OTC medications and herbal products, especially cold preparations, without consulting health care professional.
Advise patient to notify health care professional if rash, irregular heartbeats, dyspnea, swelling of hands and feet, pronounced dizziness, nau⫽ Canadian drug name.
⫽ Genetic Implication.
pg 3 # 3
sea, constipation, or hypotension occurs or if headache is severe or persistent.
Caution patient to wear protective clothing and use sunscreen to prevent photosensitivity reactions.
Angina: Instruct patient on concurrent nitrate or beta-blocker therapy to continue taking both medications as directed and to use SL nitroglycerin as needed for
anginal attacks.
Advise patient to contact health care professional if chest pain does not improve,
worsens after therapy, or occurs with diaphoresis; if shortness of breath occurs;
or if severe, persistent headache occurs.
Caution patient to discuss exercise restrictions with health care professional before exertion.
Hypertension: Encourage patient to comply with other interventions for hypertension (weight reduction, low-sodium diet, smoking cessation, moderation of alcohol consumption, regular exercise, and stress management). Medication controls but does not cure hypertension.
Instruct patient and family in proper technique for monitoring BP. Advise patient
to take BP weekly and to report significant changes to health care professional.
Evaluation/Desired Outcomes
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Decrease in BP.
Decrease in frequency and severity of anginal attacks.
Decrease in need for nitrate therapy.
Increase in activity tolerance and sense of well-being.
Suppression and prevention of tachyarrhythmias.
Why was this drug prescribed for your patient?
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
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