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Diltiazem is an oral and parenteral non-dihydropyridine calcium channel blocker. It is used in many clinical scenarios as an antihypertensive, anti-arrhythmic, and anti-anginal. FDA-approved indications include atrial arrhythmia, hypertension, paroxysmal supraventricular tachycardia, and chronic stable angina. Diltiazem also has numerous off-label indications for migraine prophylaxis, anal fissures, and pulmonary hypertension. This activity will highlight the mechanism of action, adverse event profile, approved and off-label uses, dosing, pharmacodynamics, pharmacokinetics, relevant diltiazem interactions, and monitoring of patients treated with diltiazem. It also emphasizes the pertinent interprofessional team members' role when prescribing diltiazem for any of its intended indications. Objectives: Explain the mechanisms of action for diltiazem. Identify the approved and off-label indications for diltiazem use. Review the adverse events for diltiazem therapy. Outline the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients when using diltiazem. Access free multiple choice questions on this topic.

Diltiazem is available in many dosage forms and strengths, making it imperative to be cautious when prescribing, dispensing, and administering this medication. There have been reports of diltiazem overdose in amounts ranging from <1 g to 18 g. In cases with the known outcome, most patients recovered, and in cases with a fatal outcome, the majority involved multiple drug ingestion. Clinical Features Profound bradycardia Dizziness End organ dysfunction Hypotension AV block Cardiac failure Cardiac arrest Management Treat according to ACLS protocol for arrhythmias and hypotension.[30] Whole bowel irrigation for gastrointestinal decontamination[31] Administer IV calcium gluconate or calcium chloride.[32] Administer IV atropine (0.60 to 1.0 mg) for bradycardia.[33] IV glucagon enhances intracellular levels of cyclic adenosine monophosphate and increases heart rate.[34] Severe toxicity may respond to hyperinsulinemia/euglycemia therapy(HIET).[35] Lipid emulsion therapy in significant cardiotoxicity.[36] Transvenous pacemaker to assist with electrical conduction. If there are no contraindications, an intra-aortic balloon pump can be deployed.[37] Extracorporeal membrane oxygenation is used for  Massive diltiazem overdose.[38] CCBs, including diltiazem, are extremely protein-bound; consequently, extracorporeal removal by hemodialysis is ineffective.[39] Administer vasopressors and inotropic agents (e.g., dopamine or norepinephrine) for severe hypotension and cardiac failure.[40] The use of vasopressors is common in patients with diltiazem overdose and is associated with promising clinical outcomes.[40]

Diltiazem has been widely used in practice for many clinical indications. Proper dosage and frequency are essential to enhance patient care and improve outcomes. Diltiazem possesses negative inotropic effects and is generally avoided in patients with congestive heart failure, and diltiazem is also on the Beers Criteria.[41] These factors highlight the importance of avoiding diltiazem in patients with heart failure, especially in the elderly, due to drug interactions and exacerbation of heart failure.[42] According to the study, older adults with hypertension who are prescribed calcium channel blockers, including diltiazem, are dispensed a loop diuretic at higher rates due to peripheral edema. This is an example of prescribing cascade; clinicians should re-assess the patient before prescribing a diuretic to treat peripheral edema.[43] [level 3] Ideally, Clinicians should verify drug, dose, and patient factors before administration. For example, one common error with diltiazem therapy is an incorrect dose administered to the patient. Double-checking doses can help ensure the patient receives appropriate therapeutic management in inpatient and outpatient settings. Pharmacists, nurses, and other providers should also check for potential drug interactions with other medications of the patient's profile. For example, diltiazem is available in many brand names with differing recommended dosages and maximum daily doses; this vigilance will limit drug interactions and incorrect dosing. Nursing staff should monitor for clinical improvement and any adverse drug reactions and inform the clinicians in case of any inconsistency. If the pharmacist or nurse suspects anything is amiss, they should contact the prescriber immediately.

Ideally, Clinicians should verify drug, dose, and patient factors before administration. For example, one common error with diltiazem therapy is an incorrect dose administered to the patient. Double-checking doses can help ensure the patient receives appropriate therapeutic management in inpatient and outpatient settings. Pharmacists, nurses, and other providers should also check for potential drug interactions with other medications of the patient's profile. For example, diltiazem is available in many brand names with differing recommended dosages and maximum daily doses; this vigilance will limit drug interactions and incorrect dosing. Nursing staff should monitor for clinical improvement and any adverse drug reactions and inform the clinicians in case of any inconsistency. If the pharmacist or nurse suspects anything is amiss, they should contact the prescriber immediately. In overdose, triage nurses and emergency department physicians should quickly stabilize the patient. Critical care physician supervision is necessary for severe hypotension and cardiac failure. IABP insertion requires cardiac consultation. Obtain the latest information by contacting the poison control center (800-222-1222) in the United States. As illustrated above, clinicians (MDs, DOs, NPs, PAs), specialists, nurses, pharmacists, and other healthcare providers are involved in taking care of the patient. Hence it is vital to communicate and work collaboratively for better patient outcomes related to diltiazem therapy. An interprofessional team approach involving all the providers would maximize efficacy and minimize adverse drug reactions translating to optimal patient outcomes with minimum adverse drug reactions. [Level 5]