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Diltiazem Injection (diltiazem hydrochloride)

OTHER BRAND NAMES

Cardizem Injection (Discontinued)

THERAPEUTIC CLASS

Calcium channel blocker (CCB) (nondihydropyridine)

DEA CLASS

RX

INDICATIONS

Temporary control of rapid ventricular rate in A-fib/flutter. Rapid conversion of paroxysmal supraventricular tachycardia (PSVT) to sinus rhythm.

ADULT DOSAGE

Atrial Fibrillation/Flutter

Bolus: 0.25mg/kg IV over 2 min
If no response after 15 min, may give 2nd dose of 0.35mg/kg over 2 min

Continuous Infusion: 0.25-0.35mg/kg IV bolus, then 10mg/hr
Titrate: Increase by 5mg/hr
Max: 15mg/hr and duration up to 24 hrs

DOSING CONSIDERATIONS

Elderly
Start at lower end of dosing range

ADMINISTRATION

IV route

Dilute in normal saline, D5W, or D5W/0.45% NaCl. Refer to PI for more details

Incompatibilities

Do not mix w/ any other drugs in the same container and is recommended not to be coinfused in the same IV line

Physical incompatibilities (precipitate formation or cloudiness) were observed when diltiazem was infused in the same IV line w/ the following: acetazolamide, acyclovir, aminophylline, ampicillin, ampicillin sodium/sulbactam sodium, cefamandole, cefoperazone, diazepam, furosemide, hydrocortisone sodium succinate, insulin (regular: 100 U/mL), methylprednisolone sodium succinate, mezlocillin, nafcillin, phenytoin, rifampin, and sodium bicarbonate

HOW SUPPLIED

Inj: 5mg/mL

CONTRAINDICATIONS

Sick sinus syndrome and 2nd- or 3rd-degree atrioventricular (AV) block (except with functioning pacemaker), severe hypotension, cardiogenic shock, concomitant IV β-blockers or within a few hrs of use, A-fib/flutter associated with accessory bypass tract (eg, Wolff-Parkinson-White [WPW] syndrome, short PR syndrome), ventricular tachycardia.

WARNINGS/PRECAUTIONS

Initiate in setting with resuscitation capabilities. Caution if hemodynamically compromised, and with renal, hepatic, or ventricular dysfunction. Monitor ECG continuously and BP frequently. Symptomatic hypotension, acute hepatic injury reported. D/C if high-degree AV block occurs in sinus rhythm or if persistent rash occurs. Ventricular premature beats may be present on conversion of PSVT to sinus rhythm.

ADVERSE REACTIONS

Hypotension, inj-site reactions (eg, itching, burning), vasodilation (flushing), arrhythmias.

DRUG INTERACTIONS

See Contraindications. Caution with drugs that decrease peripheral resistance, intravascular volume, myocardial contractility or conduction. Increased AUC of midazolam, triazolam, buspirone, quinidine, and lovastatin, which may require a dose adjustment due to increased clinical effects or increased adverse events. Elevates carbamazepine levels, which may result in toxicity. Cyclosporine may need dose adjustment. Potentiates the depression of cardiac contractility, conductivity, automaticity, and vascular dilation with anesthetics. Possible bradycardia, AV block, and contractility depression with oral β-blockers. Possible competitive inhibition of metabolism with drugs metabolized by CYP450. Avoid rifampin. Monitor for excessive slowing of HR and/or AV block with digoxin. Cimetidine increases peak diltiazem plasma levels and AUC.

PREGNANCY AND LACTATION

Category C, not for use in nursing.

MECHANISM OF ACTION

Calcium channel blocker; inhibits influx of Ca2+ ions during membrane depolarization of cardiac and vascular smooth muscle. Has ability to slow AV nodal conduction time and prolong AV nodal refractoriness, which has therapeutic benefits on supraventricular tachycardia. Decreases peripheral resistance, resulting in decreased systolic and diastolic BP.

PHARMACOKINETICS

Distribution: Vd=305-391L; plasma protein binding (70-80%); found in breast milk. Metabolism: Liver (extensive) via CYP450; deacetylation, N-demethylation, O-demethylation, and conjugation; N-monodesmethyldiltiazem and desacetyldiltiazem (major metabolites). Elimination: Urine and bile; T1/2=3.4 hrs (single IV inj), 4.1-4.9 hrs (constant IV infusion).

ASSESSMENT

Assess for sick sinus syndrome and 2nd- or 3rd-degree AV block, presence of functioning pacemaker, severe hypotension, cardiogenic shock, A-fib/flutter associated with accessory bypass tract (eg, WPW syndrome, short PR syndrome), ventricular tachycardia, wide complex tachycardia, acute myocardial infarction, congestive heart failure, pulmonary congestion documented by x-ray, hypertrophic cardiomyopathy, renal/hepatic impairment, pregnancy/nursing status, and possible drug interactions.

MONITORING

Initiation of therapy should be done in setting with monitoring and resuscitation capabilities, including DC cardioversion/defibrillation. Monitor BP, HR, LFTs, and ECG. Monitor for hemodynamic deterioration, ventricular fibrillation, cardiac conduction abnormalities (eg, 2nd- or 3rd-degree AV block), ventricular premature beats, dermatologic events (erythema multiforme/exfoliative dermatitis), and acute hepatic injury.

PATIENT COUNSELING

Inform that initiation of therapy should be done in a setting with monitoring and resuscitation capabilities, including DC cardioversion/defibrillation. Inform of risks/benefits and instruct to report adverse reactions. Advise to notify physician if pregnant/nursing.

STORAGE

2-8°C (36-46°F). Do not freeze. Room temperature for up to 1 month. Destroy after 1 month. Diluted Sol: D5W, 0.9% NaCl, or D5W & 0.45% NaCl: Stable at 20-25°C (68-77°F) or 2-8°C (36-46°F) for at least 24 hrs when stored in a glass or polyvinyl chloride bag.

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