Calcium Channel Blockers (CCB)

1. Calcium Channel Blockers (CCB) Maureen McGuinness, RN (Karch, 2013)

2. Learning Objectives Upon completion of this power-point presentation, the student will be able to: • Describe the three classifications of calcium channel blockers and their mode of action • Actively monitor patients for signs/symptoms and adverse reactions to calcium channel blockers, in order to respond and maintain patient safety. • Verbalize the differences between verapamil/diltiazem and amlodipine; describe their appropriate uses, in order to safely administer the medication.

3. Type/ClassMechanism of ActionIndications CCB 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)

4. CCB– Classification of Agents V binding site D binding site N binding site (Calcium channel blockers: classification, mechanism of action and indications, 2013)

5. CCB - Mechanism of Action CCB bind to specific receptor sites (Calcium channel blockers: classification, mechanism of action and indications, 2013)

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

7. 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).

8. 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).

9. Common Trade Names Cardizem (diltiazem); Norvasc (amlodipine); Calan (Verapamil)

10. 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)

11. Norvasc (amlodipine) Therapeutic Class • antihypertensives Indications • Alone or with other agents in the management of hypertension, angina pectoris, and vasospastic (Prinzmetal's) angina Evaluation/Desired Outcomes • Decrease in BP, frequency and severity of anginal attacks (Davis Drug Guide, 2013)

12. 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 Evaluation/Desired Outcomes • Decrease in BP and severity of anginal attacks • Suppression and prevention of atrial tachyarrhythmias (Davis Drug Guide, 2013)

13. ContraindicationsPrecautionsAdverse Events Dietary and Herbal Considerations

14. Contraindications (Davis Drug Guide, 2013)

15. Precautions (Davis Drug Guide, 2013)

16. Common Side Effects & Adverse Events * CAPITALS indicate life-threatening. Italics indicate most frequent (Davis Drug Guide, 2013)

17. Common Side Effects & Adverse Events * CAPITALS indicate life-threatening. Italics indicate most frequent (Davis Drug Guide, 2013)

18. Common Side Effects & Adverse Events (Davis Drug Guide, 2013)

19. Common Dietary Considerations (Davis Drug Guide, 2013)

20. Common Herbal Considerations (Karch, 2013)

21. Common Herbal Considerations (Karch, 2013)

22. Nursing Considerations

23. 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 (Davis Drug Guide, 2013)

24. 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. (Davis Drug Guide, 2013)

25. 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. (Davis Drug Guide, 2013)

26. Questions

27. Question # 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). • ARRHYTHMIAS, HF, peripheral edema, bradycardia, chest pain, hypotension, palpitations, syncope, tachycardia • Peripheral edema, angina, bradycardia, hypotension, palpitations, gingival hyperplasia, nausea, flushing • Dermatitis, erythema multiforme, flushing, photosensitivity, pruritus/urticaria, rash, sweating • ↑ liver enzymes, anorexia, constipation, diarrhea, dry mouth, dysgeusia, dyspepsia, nausea, vomiting Answer B Rationale: Norvasc (Amlodipine) is a third generation dihydropiridineswhich has minimal effect on cardiac conduction or heart rate, while having potent actions as arteriolar vasodilators.

28. Question # 2 • Mrs. Francis is currently receiving calcium channel blockers for angina. The nurse understands that she must: (Select all that apply). • Perform a physical assessment to establish baseline status before beginning therapy and during therapy • Inspect skin color and integrity • Monitor laboratory test results, including liver and renal function tests • All of the above Answer: D • 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.

29. Question # 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) • Hypotension • Palpitations • Anorexia • Increased exercise tolerance Answer: A, B, C Rationale: Hypotension, palpations and anorexia are all symptoms of adverse reactions, increased exercise tolerance is not.

30. 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.