Calcium Channel Blockers Co-prescribed with Loop Diuretics: A Potential Marker of Poor Prescribing?
Prescribing cascades are where a drug adverse reaction is wrongly attributed to the emergence of a new condition, which leads to further drug prescribing. This promotes polypharmacy, adverse drug reactions and therapeutic burden. An example of a prescribing cascade is the co-prescribing of loop diuretics to treat the peripheral oedema caused by calcium channel blocker (CCB) drugs. Although well recognised, this is still a combination of medications taken by millions of people worldwide. CCBs have no prognostic benefit in heart failure and have an absolute risk increase for oedema of around 8–18% (number needed to harm 6–13). In the treatment of hypertension, they also increase the risk of oedema and a new diagnosis of heart failure without having any major advantages over alternative drugs. The best way to manage the oedema caused by CCBs is to switch to an alternative medication. Only where this is not possible or fails to achieve therapeutic goals would the CCB–loop diuretic combination appear to be justified. In many cases, therapeutic practice could be improved by targeting people on CCB–loop diuretic combinations for medication review. This could improve quality of life and reduce polypharmacy, adverse drug reactions, therapeutic burden and financial costs for millions of people worldwide.
Compliance with Ethical Standards
No sources of funding were used to assist in the preparation of this article.
Conflict of interest
The authors declare that they have no competing interest.
- 3.Duerden M, Avery T, Payne R. Polypharmacy and medicines optimisation: making it safe and sound. The King’s Fund 2013. http://www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation. Accessed 9 July 2019.
- 22.Packer M, Carson P, Elkayam U, et al. Effect of amlodipine on the survival of patients with severe chronic heart failure due to a nonischemic cardiomyopathy: results of the PRAISE-2 study (Prospective Randomized Amlodipine Survival Evaluation 2). J Am Coll Cardiol HF. 2013;1:308–14.Google Scholar
- 26.National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. Clinical guideline 127; 2011. http://www.nice.org.uk/guidance/cg127.
- 30.Brown MJ, Palmer CR, Castaigne A, et al. Morbidity and mortality in patients randomised to double-blind treatment with a long-acting calcium-channel blocker or diuretic in the International Nifedipine GITS study: Intervention as a Goal in Hypertension Treatment (INSIGHT). Lancet. 2000;356:366–72.CrossRefGoogle Scholar
- 31.Dahlof B, Sever PS, Poulter NR, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet. 2005;366:895–906.CrossRefGoogle Scholar
- 32.The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288:2981–97.CrossRefGoogle Scholar
- 34.National Institue for Health and Care Excellence. Stable angina: management. Clinical guideline 126, 2011. http://nice.org.uk/guidance/cg126.