c alcium c hannel b lockers (ccb) maureen mcguinness, rn (karch, 2013)

CALCIUM CHANNEL BLOCKERS (CCB)Maureen McGuinness, RN

(Karch, 2013)

LEARNING OBJECTIVES

Upon completion of this power-point presentation, the student will be able to:

1) Describe the three classifications of calcium channel blockers and their

mode of action

2) Actively monitor patients for signs/symptoms and adverse reactions to

calcium channel blockers, in order to respond and maintain patient safety.

3) Verbalize the differences between verapamil/diltiazem and amlodipine;

describe their appropriate uses, in order to safely administer the

medication.

TYPE/CLASSMECHANISM OF ACTIONINDICATIONSCCB inhibit transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction.

(Calcium channel blockers: classification, mechanism of action and indications, 2013)

CCB – CLASSIFICATION OF AGENTS

V binding site

D binding site

N binding site


CCB - MECHANISM OF ACTION


CCB bind to specific receptor sites

CCB - MECHANISM OF ACTION

dihydropiridines

• Minimal effect on cardiac conduction or heart rate,

• Potent actions as arteriolar vasodilators

verapamil and diltiazem

• Slow AV conduction

• Decrease SA node automaticity

• Decrease heart rate


MECHANISM OF ACTION

• The mechanism of action of CCBs in hypertension is based on their vasodilator properties

• The effectiveness of all agents is similar, with no evidence to suggest that one drug is better than the other

• The use of the once-daily administered drug, e.g. amlodipine, felodipine and lercanidipine, is preferred to aid compliance

• Calcium channel blockers also have a role in isolated systolic hypertension in the elderly

(Salama, 2008).

INDICATIONS FOR USE

• Tissue selectivities differ between agents

• verapamil is more cardioselective

• dihydropyridines are relatively smooth muscle selective

• diltiazem has intermediate properties

• Clinical uses include hypertension, angina (by reducing cardiac work and antidysrhythmic action), and in the case or verapamil mainly in supraventricular arrhythmias.

• When prescribing refer to specific indication and license of the specific calcium channel blocker as differences exist

(Salama, 2008).

COMMON TRADE NAMESCardizem (diltiazem); Norvasc (amlodipine); Calan (Verapamil)

CARDIZEM (DILTIAZEM)

Therapeutic Class

• Antianginals, antiarrhythmics (class IV), antihypertensives

Indications

• Hypertension, Angina pectoris and vasospastic (Prinzmetal's) angina, Supraventricular tachyarrhythmias and rapid ventricular rates in atrial flutter or fibrillation

Evaluation/Desired Outcomes

• Decrease in BP, frequency and severity of anginal attacks

• Suppression and prevention of tachyarrhythmias

(Davis Drug Guide, 2013)

NORVASC (AMLODIPINE)

Therapeutic Class

• antihypertensives

Indications

• Alone or with other agents in the management of hypertension, angina pectoris, and vasospastic (Prinzmetal's) angina


• Decrease in BP, frequency and severity of anginal attacks


CALAN (VERAPAMIL)

Therapeutic Class

• Antianginals, antiarrhythmics (class IV), antihypertensives, vascular headache suppressants

Indications

• Management of hypertension, angina pectoris, and/or vasospastic (Prinzmetal's) angina

• Management of supraventricular arrhythmias and rapid ventricular rates in atrial flutter or fibrillation


• Decrease in BP and severity of anginal attacks

• Suppression and prevention of atrial tachyarrhythmias


CONTRAINDICATIONSPRECAUTIONSADVERSE EVENTS DIETARY AND HERBAL CONSIDERATIONS

CONTRAINDICATIONSCardizem (diltiazem) Norvasc (amlodipine) Calan (Verapamil)

• 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.

• Hypersensitivity;

• Systolic BP <90 mm Hg.

• Hypersensitivity

• Sick sinus syndrome

• 2nd- or 3rd-degree AV block (unless an artificial pacemaker is in place)

• Systolic BP <90 mm Hg

• HF, severe ventricular dysfunction, or cardiogenic shock, unless associated with supraventricular tachyarrhythmias;

• Concurrent IV beta blocker therapy


PRECAUTIONSCardizem (diltiazem) Norvasc (amlodipine) Calan (Verapamil)

• Severe hepatic impairment (↓ dose recommended)

• Geri: ↓ dose; slower IV infusion rate recommended; ↑ risk of hypotension; consider age-related decrease in body mass, ↓ hepatic/renal/cardiac function, concurrent drug therapy and other disease states

• Severe renal impairment• Serious ventricular

arrhythmias or HF• OB: Lactation: Pedi: Safety

not established.

• Severe hepatic impairment (↓ dose recommended)

• Aortic stenosis;• History of HF;• OB: Lactation: Pedi: Safety

not established;• Geri: (↓ dose recommended)• ↑ risk of hypotension.

• Severe hepatic impairment(↓ dose recommended)

• History of serious ventricular arrhythmias or HF;

• Geri: Dose ↓/slower IV infusion rates recommended (↑ risk of hypotension);

• OB: Lactation: Safety not established.


COMMON SIDE EFFECTS & ADVERSE EVENTSSystem Cardizem (diltiazem) Norvasc

(amlodipine) Calan (Verapamil)

CV

ARRHYTHMIAS, HF, peripheral edema, bradycardia, chest pain, hypotension, palpitations, syncope, tachycardia

peripheral edema, angina, bradycardia, hypotension, palpitations

ARRHYTHMIAS, HF, bradycardia, chest pain, hypotension, palpitations, peripheral edema, syncope, tachycardia

GI

↑ liver enzymes, anorexia, constipation, diarrhea, dry mouth, dysgeusia, dyspepsia, nausea, vomiting

gingival hyperplasia, nausea

↑ liver enzymes, anorexia, constipation, diarrhea, dry mouth, dysgeusia, dyspepsia, nausea, vomiting

GUdysuria, nocturia, polyuria, sexual dysfunction, urinary frequency

dysuria, nocturia, polyuria, sexual dysfunction, urinary frequency

* CAPITALS indicate life-threatening. Italics indicate most frequent (Davis Drug Guide, 2013)



DERM

STEVENS-JOHNSON SYNDROME, dermatitis, erythema multiforme, flushing, sweating, photosensitivity, pruritus/urticaria, rash

flushing

dermatitis, erythema multiforme, flushing, photosensitivity, pruritus/urticaria, rash, sweating

ENDO gynecomastia, hyperglycemia

gynecomastia, hyperglycemia

HEMAT anemia, leukopenia, thrombocytopenia

anemia, leukopenia, thrombocytopenia

METAB weight gain weight gain

MS joint stiffness, muscle cramps

joint stiffness, muscle cramps

* CAPITALS indicate life-threatening. Italics indicate most frequent (Davis Drug Guide, 2013)



NEURO paresthesia, tremor paresthesia, tremor

MISC gingival hyperplasiaSTEVENS-JOHNSON SYNDROME, gingival hyperplasia


COMMON DIETARY CONSIDERATIONSCardizem (diltiazem)

Norvasc (amlodipine) Calan (Verapamil)

DIETARY Grapefruit juice ↑ levels and effect.

Grapefruit juice ↑ serum levels and effect.

Grapefruit juice ↑ serum levels and effect.↑ caffeine levels with caffeine-containing herbs (cola nut, guarana, mate, tea, coffee).


COMMON HERBAL CONSIDERATIONSHerbs Cardizem

(diltiazem)Norvasc (amlodipine) Calan (Verapamil)

Arnica May effectiveness of antihypertensives

Astragalus, Barberry May ↑effectiveness of antihypertensives

Bayberry May block effects of antihypertensives

Black cohosh root May lower blood pressureCats claw, parsley seeds, Increased hypotension when taken with antihypertensives

Chinese angelica Monitor patients on antihypertensives for toxic effects

Coleus forskolin Use caution when taking with antihypertensives, severe additive effects can occur

DHEA Risk of interactions with calcium channel blockers

(Karch, 2013)

COMMON HERBAL CONSIDERATIONSHerbs Cardizem

(diltiazem)Norvasc (amlodipine) Calan (Verapamil)

DHEA Risk of interactions with calcium channel blockers

Goldenseal May interfere with antihypertensivesGuayusa, melatonin, mistletoe leaves, rue extract

Advise caution with antihypertensives

Mau huang Warn against use with antihypertensives

(Karch, 2013)

NURSING CONSIDERATIONS

NURSING CONSIDERATIONS VERAPAMIL AND DILTIAZEM

• Monitor BP and pulse before, during titration and periodically during therapy.

• Monitor ECG periodically during prolonged therapy.

• Monitor intake and output ratios and daily weight.

• Assess for rash and signs of HF.

• Monitor patient compliance with medication regimen.

• Monitor routine serum digoxin levels for signs and symptoms of digoxin toxicity.

• For treatment of Angina monitor for location, duration, intensity, and precipitating factors of patient's anginal pain

• For treatment of Arrhythmias monitor EKG report bradycardia or prolonged hypotension promptly


LAB CONSIDERATIONS: VERAPAMIL AND DILTIAZEM

• Total serum calcium concentrations are not affected by calcium channel blockers.

• Monitor serum potassium periodically. Hypokalemia ↑ risk of arrhythmias and should be corrected.

• Monitor renal and hepatic functions periodically during long-term therapy. May cause ↑ hepatic enzymes after several days of therapy, which return to normal on discontinuation of therapy.


NURSING CONSIDERATIONS:AMLODIPINE

• Monitor BP and pulse before therapy, during dose titration, and periodically during therapy. Monitor ECG periodically during prolonged therapy.

• Monitor intake and output ratios and daily weight. Assess for signs of HF (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention).

• Angina: Assess location, duration, intensity, and precipitating factors of patient's anginal pain.

Lab Test Considerations:

• Total serum calcium concentrations are not affected by calcium channel blockers.


QUESTIONS

QUESTION # 1

1) Mr. Jones is being discharged from the hospital with a new prescription for Norvasc (amlodipine) for hypertension. He is concerned about the side effects. The nurse explains common side effects include: (Choose the best answer).

a) ARRHYTHMIAS, HF, peripheral edema, bradycardia, chest pain, hypotension, palpitations, syncope, tachycardia

b) Peripheral edema, angina, bradycardia, hypotension, palpitations, gingival hyperplasia, nausea, flushing

c) Dermatitis, erythema multiforme, flushing, photosensitivity, pruritus/urticaria, rash, sweating

d) ↑ liver enzymes, anorexia, constipation, diarrhea, dry mouth, dysgeusia, dyspepsia, nausea, vomiting

Answer B

Rationale: Norvasc (Amlodipine) is a third generation dihydropiridines which has minimal effect on cardiac conduction or heart rate, while having potent actions as arteriolar vasodilators.

QUESTION # 2

2) Mrs. Francis is currently receiving calcium channel blockers for angina. The nurse understands that she must: (Select all that apply).

a) Perform a physical assessment to establish baseline status before beginning therapy and during therapy

b) Inspect skin color and integrity

c) Monitor laboratory test results, including liver and renal function tests

d) All of the above

Answer: D

e) Rationale: Establish baseline to determine the effectiveness and evaluate for any potential adverse events. Inspect skin color and integrity to identify possible adverse skin reactions. Monitor lab results to determine the need for possible dose adjustments.

QUESTION # 3

3) After teaching a patient who is receiving verapamil for long-term treatment of angina, the nurse determines that the patient has understood the teaching when the patient identifies what potential adverse effect? (Select all that apply)

a) Hypotension

b) Palpitations

c) Anorexia

d) Increased exercise tolerance

Answer: A, B, C

Rationale: Hypotension, palpations and anorexia are all symptoms of adverse reactions, increased exercise tolerance is not.

REFERENCES

Calcium channel blockers: classification, mechanism of action and indications. (2013).

Retrieved November 21, 2013, from Pharmacology Corner: http://

pharmacologycorner.com/calcium-

Davis Drug Guide. (2013, August 20). Retrieved from Nursing Central:

http://nursing.unboundmedicine.com/nursingcentral/ub

Karch, A. M. (2013). Focus on nursing pharmacology. Philadelphia: Wolters Kluwer

Health/Lippincott Williams & Wilkin.

Salama, R. (2008). Calcium channel blockers: uses and prescribing rationale. Nurse

Prescribing, 6(4), 168-172.

http://pharmacologycorner.com/calcium-



c alcium c hannel b lockers (ccb) maureen mcguinness, rn (karch, 2013)

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