BNF for Children 2011-2012

106 2.6.2 Calcium-channel blockers BNFC 2011–20122 Cardiovascular systemment of hypertension. Side-effects associated with vasodilatationsuch as flushing and headache (which becomeless obtrusive after a few days), and ankle swelling(which may respond only partially to diuretics) arecommon.Nimodipine is related to nifedipine but the smoothmuscle relaxant effect preferentially acts on cerebralarteries. Its use is confined to prevention and treatmentof vascular spasm following aneurysmal subarachnoidhaemorrhage.Diltiazem is a peripheral vasodilator and also has milddepressor effects on the myocardium. It is used in thetreatment of Raynaud’s syndrome.Withdrawal There is some evidence that suddenwithdrawal of calcium-channel blockers may be associatedwith an exacerbation of myocardial ischaemia.AMLODIPINECautions acute porphyria (but see section 9.8.2);interactions: Appendix 1 (calcium-channel blockers)Contra-indications cardiogenic shock, significantaortic stenosisHepatic impairment may need dose reduction—halflifeprolongedPregnancy no information available—manufactureradvises avoid, but risk to fetus should be balancedagainst risk of uncontrolled maternal hypertensionBreast-feeding manufacturer advises avoid—noinformation availableSide-effects abdominal pain, nausea; palpitation,flushing, oedema; headache, dizziness, sleep disturbances,fatigue; less commonly gastro-intestinal disturbances,dry mouth, taste disturbances, hypotension,syncope, chest pain, dyspnoea, rhinitis, moodchanges, asthenia, tremor, paraesthesia, urinary disturbances,impotence, gynaecomastia, weightchanges, myalgia, muscle cramps, back pain, arthralgia,visual disturbances, tinnitus, pruritus, rashes(including isolated reports of erythema multiforme),sweating, alopecia, purpura, and skin discolouration;very rarely gastritis, pancreatitis, hepatitis, jaundice,cholestasis, gingival hyperplasia, myocardial infarction,arrhythmias, tachycardia, vasculitis, coughing,peripheral neuropathy, hyperglycaemia, thrombocytopenia,angioedema, and urticariaLicensed use not licensed for use in children under 6yearsIndication and doseHypertension. By mouthChild 1 month–12 years initially 100–200 micrograms/kgonce daily; if necessary increase atintervals of 1–2 weeks up to 400 micrograms/kgonce daily; max. 10 mg once dailyChild 12–18 years initially 5 mg once daily; ifnecessary increase at intervals of 1–2 weeks tomax. 10 mg once dailyAdministration tablets may be dispersed in waterNote Tablets from various suppliers may contain different salts(e.g. amlodipine besilate, amlodipine maleate, and amlodipinemesilate) but the strength is expressed in terms of amlodipine(base); tablets containing different salts are considered interchangeableAmlodipine (Non-proprietary) ATablets, amlodipine (as maleate or as mesilate) 5 mg,net price 28-tab pack = £1.05; 10 mg, 28-tab pack =£1.20Brands include Amlostin cIstin c (Pfizer) ATablets, amlodipine (as besilate) 5 mg, net price 28-tab pack = £11.08; 10 mg, 28-tab pack = £16.55Extemporaneous formulations available seeExtemporaneous Preparations, p. 6DILTIAZEM HYDROCHLORIDECautions heart failure or significantly impaired leftventricular function, bradycardia (avoid if severe), firstdegree AV block, or prolonged PR interval; interactions:Appendix 1 (calcium-channel blockers)Contra-indications severe bradycardia, significantaortic stenosis, cardiogenic shock, left ventricularfailure with pulmonary congestion, second- or thirddegreeAV block (unless pacemaker fitted), sick sinussyndrome; acute porphyria (section 9.8.2)Hepatic impairment reduce doseRenal impairment start with smaller dosePregnancy avoidBreast-feeding significant amount present in milk—no evidence of harm but avoid unless no safer alternativeSide-effects bradycardia, sino-atrial block, AV block,palpitation, dizziness, hypotension, malaise, asthenia,headache, hot flushes, gastro-intestinal disturbances,oedema (notably of ankles); rarely rashes (includingerythema multiforme and exfoliative dermatitis),photosensitivity; hepatitis, gynaecomastia, gumhyperplasia, extrapyramidal symptoms, depressionreportedLicensed use not licensed for use in childrenIndication and doseRaynaud’s syndrome. By mouthChild 12–18 years 30–60 mg 2–3 times dailyStandard formulationsNote These formulations are licensed as generics and there isno requirement for brand name dispensing. Although theirmeans of formulation has called for the strict designation‘modified-release’ their duration of action corresponds to thatof tablets requiring administration more frequentlyDiltiazem (Non-proprietary) ATablets, m/r (but see note above), diltiazem hydrochloride60 mg, net price 84-tab pack = £2.93.Label: 25Brands include Optil cTildiem c (Sanofi-Aventis) ATablets, m/r (but see note above), off-white, diltiazemhydrochloride 60 mg, net price 90-tab pack = £7.96.Label: 25NICARDIPINE HYDROCHLORIDECautions congestive heart failure or significantlyimpaired left ventricular function; avoid grapefruitjuice (may affect metabolism); interactions: Appendix1 (calcium-channel blockers)Contra-indications cardiogenic shock; significantaortic stenosis; acute porphyria (section 9.8.2)