1. Calcium channel blockers

Last updated on June 18, 2019 at 21:28

Calcium channels

Many types of calcium channels exist: voltage-gated (L, N, T and R types), ligand gated (IP3 receptor, ryanodine receptor) and store-operated types. However, only the voltage-gated L-type channels are important therapeutically. When we talk about calcium channel blockers we mean those drugs that inhibit the action of L-type calcium channels.

L-type calcium channels are voltage-gated channels that are found on the cardiac pacemakers, smooth (vascular) muscle and cardiac muscle. This channel is the main source of Ca2+ needed for contraction in these types of muscle. The action potential arrives, the membrane is depolarized, the channels open and Ca2+ flows into the cell which causes the contraction.

The channels have 5 subunits: α1, α2, β, γ and δ.

Calcium channel blockers

Also called calcium antagonists or calcium entry blockers, these drugs bind to a binding site on the α1 subunit. This messes with the “gating” machinery, which reduces the channel’s ability to open correctly.

Three types exist:

  • Phenylkylamines like verapamil
  • Benzothiazepines like diltiazem
  • Dihydropyridines (DHPs) like nifedipine

Verapamil and diltiazem work on both cardiac and vascular muscle, while DHPs work mostly on vascular muscle. Therefore do all three drugs have similar vascular effects, while only verapamil and diltiazem have significant cardiac effects, so we’ll talk about them together.

Vascular effects

All three drug types produce vascular effects.

By inhibiting contraction in vascular smooth muscle these drugs cause vasodilation with resulting decrease in peripheral resistance. The coronaries are also vasodilated.

The vasodilatory effect of these drugs may activate the baroreflex, which causes increased sympathetic tone and tachycardia. This occurs mostly in fast-acting DHPs, but also partially in diltiazem. The sympathetic activation of the heart in patients taking verapamil is completely counteracted by the effects of verapamil. Therefore will verapamil cause bradycardia while diltiazem produces no net change in heart rate.

Cardiac effects

Verapamil and diltiazem prevent calcium from entering through L-type channels in the SA node, the AV node and the myocardial fibres, causing negative heart effects:

  • Negative chronotropic effect – decreased heart rate
  • Negative inotropic effect – decreased contractility
  • Negative dromotropic effect – decreased conduction velocity
  • Negative bathmotropic effect – decreased excitability

There are also the indirect positive heart effects due to the baroreflex.

Verapamil and diltiazem

These drugs have both vascular and cardiac effects. Verapamil has stronger cardiac effects than diltiazem.

Indications:

Angina pectoris, supraventricular tachycardias, hypertrophic cardiomyopathy, hypertension.

Mechanism of action:

These drugs inhibit calcium channels in vascular smooth muscle and cardiac muscle.

They importantly vasodilate the coronaies, which gives more blood to the myocardium, and due to the negative chronotropic and inotropic effects, which decreases the O2 demand of the myocardium.

Contraindications:

Their use in patients with heart failure is not recommended, as the negative inotropic effect may worsen it.

They’re also contraindicated in bradycardia, sick sinus syndrome, AV-block and hypotension, also due to the negative heart effects.

Pharmacokinetics:

They have good oral absorption but significant first-pass effect. The administered dose should therefore be reduced in liver failure. They have extensive plasma protein binding and a Vd > 1L/kg, meaning that they accumulate in tissues. They’re eliminated by biotransformation by CYP3A4 and CYP1A2 and can be given orally or IV.

Interactions:

They should not be combined with other drugs that give negative heart effects, like beta blockers or digitalis drugs. Verapamil even decreases renal elimination of digoxin, so using those two together would be especially bad.

Dihydropyridines

DHPs are classified according to their duration of action:

  • Short-and-rapidly acting
    • Nifedipine
    • Nimodipine
    • Nicardipine
  • Intermediate-acting
    • Nitredipine
    • Isradipine
  • Long-and-slowly acting
    • Amlodipine
    • Lacidipine

These drugs have no cardiac effects in therapeutic dose, only vascular effects. They may cause reflex positive heart effects due to the baroreflex, however this problem doesn’t occur with slower acting DHPs.

Because they have no negative heart effects they can be given with beta blockers.

Indications:

Hypertension, angina pectoris and vasospastic diseases. Only slow-acting drugs should be used for angina pectoris to prevent reflex tachycardia.

Nifedipine is given as a chewing tablet or oral spray to treat hypertensive emergencies.

Pharmacokinetics:

DHPs have good oral absorption but extensive first-pass effect. They have extensive plasma protein binding and accumulate in tissues (Vd > 1L/kg), are eliminated by biotransformation by CYP3A4 and can be given orally. One type can be given IV as well.

Contraindications:

They’re contraindicated in unstable angina and acute myocardial infarction, due to the reflex tachycardia, which may increase the O2 demand of the myocardium.

Side effects:

The short-and-rapidly acting DHPs strongly evoke the baroreflex, causing a strong reflex sympathetic activation. Giving them with beta blockers can prevent the baroreflex-mediated positive heart effects.

The slowly-and-long acting DHPs cause minimal reflex sympathetic activation.

This video is made by my good friends Majed Al-sheikh and Husam Alsallal to help people with pharmacology 2. They’re fourth year students at POTE at the time of writing. Give them a like if you liked it!


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2. Drugs acting on the renin-angiotensin-aldosterone system

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