Diltiazem
Clinical data
Pronunciation/dɪlˈtaɪəzɛm/
Trade namesCardizem, Dilacor XR, Cartia XT, others
AHFS/Drugs.comMonograph
MedlinePlusa684027
License data
Pregnancy
category
Routes of
administration		By mouth, intravenous
Drug classNondihydropyridine calcium channel blocker
ATC code
Legal status
Legal status
Pharmacokinetic data
Bioavailability40%
MetabolismLiver
Elimination half-life3–4.5 hours
ExcretionKidney
Bile duct
Identifiers
  • cis-(+)-[2-(2-Dimethylaminoethyl)-5-(4-methoxyphenyl)-3-oxo-6-thia-2-azabicyclo[5.4.0]undeca-7,9,11-trien-4-yl]ethanoate
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
PDB ligand
CompTox Dashboard (EPA)
ECHA InfoCard100.050.707 Edit this at Wikidata
Chemical and physical data
FormulaC22H26N2O4S
Molar mass414.52 g·mol−1
3D model (JSmol)
  • O=C2N(c3c(S[C@@H](c1ccc(OC)cc1)[C@H]2OC(=O)C)cccc3)CCN(C)C
  • InChI=1S/C22H26N2O4S/c1-15(25)28-20-21(16-9-11-17(27-4)12-10-16)29-19-8-6-5-7-18(19)24(22(20)26)14-13-23(2)3/h5-12,20-21H,13-14H2,1-4H3/t20-,21+/m1/s1 checkY
  • Key:HSUGRBWQSSZJOP-RTWAWAEBSA-N checkY
  (verify)

Diltiazem, sold under the brand name Cardizem among others, is a nondihydropyridine calcium channel blocker medication used to treat high blood pressure, angina, and certain heart arrhythmias.[8] It may also be used in hyperthyroidism if beta blockers cannot be used.[8] It is taken by mouth or injection into a vein.[8] When given by injection, effects typically begin within a few minutes and last a few hours.[8]

Common side effects include swelling, dizziness, headaches, and low blood pressure.[8] Other severe side effects include an overly slow heart beat, heart failure, liver problems, and allergic reactions.[8] Use is not recommended during pregnancy.[8] It is unclear if use when breastfeeding is safe.[1]

Diltiazem works by relaxing the smooth muscle in the walls of arteries, resulting in them opening and allowing blood to flow more easily.[8] Additionally, it acts on the heart to prolong the period until it can beat again.[9] It does this by blocking the entry of calcium into the cells of the heart and blood vessels.[10] It is a class IV antiarrhythmic.[11]

Diltiazem was approved for medical use in the United States in 1982.[8] It is available as a generic medication.[8] In 2020, it was the 76th most commonly prescribed medication in the United States, with more than 9 million prescriptions.[12][13] An extended release formulation is also available.[8][14]

Medical uses

Diltiazem is indicated for:

For supraventricular tachycardias (PSVT), diltiazem appears to be as effective as verapamil in treating re-entrant supraventricular tachycardia.[17]

Atrial fibrillation[18] or atrial flutter is another indication. The initial bolus should be 0.25 mg/kg, intravenous (IV).

Because of its vasodilatory effects, diltiazem is useful for treating hypertension. Calcium channel blockers are well tolerated, and especially effective in treating low-renin hypertension.[19]

It is also used as topical application for anal fissures because it promotes healing due to its vasodilatory property.[20]

Contraindications and precautions

Diltiazem is relatively contraindicated in the presence of sick sinus syndrome, atrioventricular node conduction disturbances, bradycardia, impaired left ventricle function, peripheral artery occlusive disease, and chronic obstructive pulmonary disease.

Side effects

A reflex sympathetic response, caused by the peripheral dilation of vessels and the resulting drop in blood pressure, works to counteract the negative inotropic, chronotropic and dromotropic effects of diltiazem. Undesirable effects include hypotension, bradycardia, dizziness, flushing, fatigue, headaches and edema.[21] Rare side effects are congestive heart failure, myocardial infarction, and hepatotoxicity.[22]

Diltiazem is one of the most common drugs that cause drug-induced lupus, along with hydralazine, procainamide, isoniazid, minocycline.[23]

Drug interactions

Because of its inhibition of hepatic cytochromes CYP3A4, CYP2C9 and CYP2D6, there are a number of drug interactions.[24] Some of the more important interactions are listed below.

Beta-blockers

Intravenous diltiazem should be used with caution with beta-blockers because, while the combination is most potent at reducing heart rate, there are rare instances of dysrhythmia and AV node block.[25]

Quinidine

Quinidine should not be used concurrently with calcium channel blockers because of reduced clearance of both drugs and potential pharmacodynamic effects at the SA and AV nodes.[26]

Fentanyl

Concurrent use of fentanyl with diltiazem, or any other CYP3A4 inhibitors, as these medications decrease the breakdown of fentanyl and thus increase its effects.[27]

Mechanism of action

180 mg Cardizem capsule

Diltiazem, also known as (2S,3S)-3-acetoxy-5-[2-(dimethylamino)ethyl]-2,3-dihydro-2-(4-methoxyphenyl)-1,5-benzothiazepin-4(5H)-one hydrochlorid has a vasodilating activity attributed to the (2S,3S)-isomer.[28] Diltiazem is a potent vasodilator, increasing blood flow and variably decreasing the heart rate via strong depression of A-V node conduction. It binds to the alpha-1 subunit of L-type calcium channels in a fashion somewhat similar to verapamil, another nondihydropyridine (non-DHP) calcium channel blocker.[29] Chemically, it is based upon a 1,4-thiazepine ring, making it a benzothiazepine-type calcium channel blocker.

It is a potent and mild vasodilator of coronary and peripheral vessels, respectively,[30] which reduces peripheral resistance and afterload, though not as potent as the dihydropyridine (DHP) calcium channel blockers. This results in minimal reflexive sympathetic changes.[citation needed]

Diltiazem has negative inotropic, chronotropic, and dromotropic effects. This means diltiazem causes a decrease in heart muscle contractility – how strong the beat is, lowering of heart rate – due to slowing of the sinoatrial node, and a slowing of conduction through the atrioventricular node – increasing the time needed for each beat. Each of these effects results in reduced oxygen consumption by the heart, reducing angina, typically unstable angina, symptoms. These effects also reduce blood pressure by causing less blood to be pumped out.

Research

Diltiazem is prescribed off-label by doctors in the US for prophylaxis of cluster headaches. Some research on diltiazem and other calcium channel antagonists in the treatment and prophylaxis of migraine is ongoing.[15][31][32][33][34][35][36][needs update]

Recent research[when?] has shown diltiazem may reduce cocaine cravings in drug-addicted rats.[37] This is believed to be due to the effects of calcium blockers on dopaminergic and glutamatergic signaling in the brain.[38] Diltiazem also enhances the analgesic effect of morphine in animal tests, without increasing respiratory depression,[39] and reduces the development of tolerance.[40]

Diltiazem is also being used in the treatment of anal fissures. It can be taken orally or applied topically with increased effectiveness.[41] When applied topically, it is made into a cream form using either vaseline or Phlojel. Phlojel absorbs the diltiazem into the problem area better than the vaseline base. It has good short-term success rates.[42][43]

References

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  2. ^ "Dilcardia SR 120 mg Prolonged-release hard capsules – Summary of Product Characteristics (SmPC)". emc. 22 March 2018. Archived from the original on 28 August 2021. Retrieved 13 April 2020.
  3. ^ "Angitil SR/XL Capsules – Summary of Product Characteristics (SmPC)". (emc). 7 May 2019. Retrieved 13 April 2020.
  4. ^ "Cardizem- diltiazem hydrochloride tablet, coated". DailyMed. 2 June 2020. Retrieved 23 October 2022.
  5. ^ "Cardizem CD- diltiazem hydrochloride capsule, coated, extended release". DailyMed. 30 April 2020. Retrieved 23 October 2022.
  6. ^ "Cardizem LA- diltiazem hydrochloride tablet, extended release". DailyMed. 2 May 2019. Retrieved 23 October 2022.
  7. ^ "Active substance(s): diltiazem" (PDF). European Medicines Agency. 11 January 2018.
  8. ^ a b c d e f g h i j k "Diltiazem Hydrochloride Monograph for Professionals". Drugs.com. AHFS. Retrieved 28 December 2018.
  9. ^ Cardiovascular Pharmacotherapeutics. Cardiotext Publishing. 2011. pp. 251–52. ISBN 978-1935395621. Retrieved 28 December 2018.
  10. ^ 2010 Nurse's Drug Handbook. Jones & Bartlett Learning. 2010. p. 320. ISBN 978-0763779009.
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  12. ^ "The Top 300 of 2020". ClinCalc. Retrieved 7 October 2022.
  13. ^ "Diltiazem – Drug Usage Statistics". ClinCalc. Retrieved 7 October 2022.
  14. ^ "Diltiazem hydrochloride – diltiazem hydrochloride extended-release tablets tablet, extended release". DailyMed. 1 April 2019. Retrieved 13 April 2020.
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  27. ^ "Drug interactions: Interactions between fentanyl and drugs that inhibit CYP3A4". Archived from the original on 3 December 2017. Retrieved 26 June 2019.
  28. ^ Matsumae H, Akatsuka H, Shibatani T (2010). "Diltiazem Synthesis". Encyclopedia of Industrial Biotechnology. pp. 1–20. doi:10.1002/9780470054581.eib603. ISBN 978-0471799306.
  29. ^ O'Connor SE, Grosset A, Janiak P (1999). "The pharmacological basis and pathophysiological significance of the heart rate-lowering property of diltiazem". Fundamental & Clinical Pharmacology. 13 (2): 145–153. doi:10.1111/j.1472-8206.1999.tb00333.x. PMID 10226758. S2CID 20440286.
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  34. ^ Paterna S, Martino SG, Campisi D, Cascio Ingurgio N, Marsala BA (July 1990). "[Evaluation of the effects of verapamil, flunarizine, diltiazem, nimodipine and placebo in the prevention of hemicrania. A double-blind randomized cross-over study]". La Clinica Terapeutica. 134 (2): 119–125. PMID 2147612.
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  37. ^ Common Heart Drug May Reduce Cocaine Cravings. Sciencedaily.com (28 February 2008). Retrieved on 2012-10-21.
  38. ^ Mills K, Ansah TA, Ali SF, Mukherjee S, Shockley DC (July 2007). "Augmented behavioral response and enhanced synaptosomal calcium transport induced by repeated cocaine administration are decreased by calcium channel blockers". Life Sciences. 81 (7): 600–608. doi:10.1016/j.lfs.2007.06.028. PMC 2765982. PMID 17689567.
  39. ^ Kishioka S, Ko MC, Woods JH (May 2000). "Diltiazem enhances the analgesic but not the respiratory depressant effects of morphine in rhesus monkeys". European Journal of Pharmacology. 397 (1): 85–92. doi:10.1016/S0014-2999(00)00248-X. PMID 10844102.
  40. ^ Verma V, Mediratta PK, Sharma KK (July 2001). "Potentiation of analgesia and reversal of tolerance to morphine by calcium channel blockers". Indian Journal of Experimental Biology. 39 (7): 636–642. PMID 12019755.
  41. ^ Jonas M, Neal KR, Abercrombie JF, Scholefield JH (August 2001). "A randomized trial of oral vs. topical diltiazem for chronic anal fissures". Diseases of the Colon and Rectum. 44 (8): 1074–1078. doi:10.1007/BF02234624. PMID 11535842. S2CID 40406260.
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  43. ^ Sajid MS, Rimple J, Cheek E, Baig MK (January 2008). "The efficacy of diltiazem and glyceryltrinitrate for the medical management of chronic anal fissure: a meta-analysis". International Journal of Colorectal Disease. 23 (1): 1–6. doi:10.1007/s00384-007-0384-x. PMID 17846781. S2CID 13015745.

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