Felodipine

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Felodipine on Prescriptsy

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Felodipine is a prescription-only medicine used to treat high blood pressure (hypertension) and stable angina pectoris.

It belongs to a class of medicines called dihydropyridine calcium channel blockers and is available as modified-release tablets in strengths of 2.5 mg, 5 mg, and 10 mg.

Felodipine works by relaxing and widening the arteries, which lowers blood pressure and improves blood flow to the heart.

It is available as a generic medicine or under the brand name Plendil.

Hypertension is one of the most significant modifiable risk factors for cardiovascular disease in the United Kingdom.

According to the British Heart Foundation, around a third of adults in the UK have high blood pressure, and many are unaware of their condition because it rarely causes symptoms until serious damage has occurred.

Left untreated, sustained high blood pressure increases the risk of stroke, heart attack, heart failure, chronic kidney disease, and vascular dementia.

Stable angina, characterised by predictable chest pain or tightness triggered by physical exertion or emotional stress, affects approximately 2 million people in the UK and is caused by reduced blood supply to the heart muscle through narrowed coronary arteries.

This page provides a comprehensive clinical overview of felodipine, including how it works, who should take it, dosing guidance, potential side effects, important safety warnings, and how to obtain a prescription in the United Kingdom.

Important safety information about felodipine

Before reading further, note the following essential safety points about felodipine.

• Felodipine is a prescription-only medicine (POM) and must be used under medical supervision.
• Swallow modified-release tablets whole. Do not crush, chew, or break them.
• Avoid grapefruit and grapefruit juice during treatment, as they significantly increase felodipine levels in the blood.
• Do not stop taking felodipine suddenly without medical advice, particularly if you take it for angina.
• Felodipine is not recommended during pregnancy or breastfeeding.

Understanding hypertension and stable angina

Blood pressure is the force exerted by circulating blood against the walls of the arteries.

It is measured in millimetres of mercury (mmHg) and recorded as two numbers: systolic pressure (when the heart contracts) over diastolic pressure (when the heart relaxes).

NICE guideline NG136 defines hypertension as a clinic blood pressure of 140/90 mmHg or higher, confirmed by ambulatory or home blood pressure monitoring showing an average of 135/85 mmHg or above.

Hypertension is classified into stages: stage 1 (clinic reading 140/90 to 159/99), stage 2 (160/100 to 179/119), and stage 3 or severe (180/120 or above).

Most people with hypertension have no symptoms, which is why it is often called the "silent killer." Diagnosis is typically made during routine health checks.

Once diagnosed, treatment aims to reduce blood pressure to below 140/90 mmHg (or below 130/80 mmHg for patients with type 2 diabetes, chronic kidney disease, or established cardiovascular disease).

Lifestyle modifications including dietary changes, weight management, regular exercise, reduced alcohol intake, and smoking cessation are recommended for all patients.

When lifestyle measures alone are insufficient, antihypertensive medication is initiated.

Stable angina occurs when the heart muscle does not receive enough oxygenated blood to meet its demands, usually because one or more coronary arteries are narrowed by atherosclerotic plaques.

Symptoms typically include chest pain, tightness, or heaviness that occurs during physical activity or stress and is relieved by rest or glyceryl trinitrate (GTN) spray.

Treatment of stable angina aims to relieve symptoms and reduce the risk of cardiovascular events.

NICE guideline CG126 recommends a beta-blocker or calcium channel blocker as first-line anti-anginal therapy.

How felodipine works: mechanism of action

Calcium ions play a central role in the contraction of smooth muscle cells in artery walls.

When calcium enters the cell through L-type voltage-gated calcium channels, it triggers a cascade of events that causes the muscle to contract and the artery to narrow.

Felodipine selectively blocks these L-type calcium channels in vascular smooth muscle, preventing calcium entry and causing the muscle to relax.

This produces dilatation of peripheral arteries and coronary arteries.

Unlike non-dihydropyridine calcium channel blockers such as verapamil and diltiazem, felodipine has a high degree of vascular selectivity and minimal direct effects on cardiac conduction or contractility at therapeutic doses.

This makes it suitable for patients who need blood pressure lowering without the risk of slowing the heart rate or worsening heart block.

The reduction in peripheral vascular resistance produced by felodipine lowers both systolic and diastolic blood pressure.

In stable angina, two mechanisms provide benefit: dilatation of coronary arteries improves oxygen delivery to the myocardium, and reduction in afterload (the resistance the heart pumps against) decreases myocardial oxygen demand.

The modified-release formulation ensures a smooth, sustained reduction in blood pressure over 24 hours, minimising the peaks and troughs in drug concentration that can cause reflex tachycardia.

Clinical evidence and UK prescribing guidance

Felodipine has been available in the UK since the early 1990s and has an extensive evidence base.

The HOT (Hypertension Optimal Treatment) trial, which enrolled nearly 19,000 patients worldwide, used felodipine as the foundation of a stepped-care antihypertensive regimen and demonstrated significant reductions in cardiovascular events with intensive blood pressure lowering.

The FEVER (Felodipine Event Reduction) study showed that adding felodipine to low-dose thiazide therapy reduced the risk of stroke and cardiovascular events compared with placebo.

NICE guideline NG136 recommends calcium channel blockers as a first-line treatment for hypertension in patients aged 55 and over, in patients of Black African or African-Caribbean descent of any age, and as step 2 add-on therapy for patients already taking an ACE inhibitor or angiotensin receptor blocker.

Felodipine is listed in the British National Formulary (BNF) as a suitable dihydropyridine calcium channel blocker for these indications.

For stable angina, NICE CG126 recommends a beta-blocker or calcium channel blocker as initial monotherapy, with the option of combining both classes if single-agent treatment is insufficient.

The choice between different dihydropyridine calcium channel blockers (felodipine, amlodipine, nifedipine modified-release, lercanidipine) depends on individual patient factors, tolerability, and cost.

All are effective antihypertensives with broadly similar clinical outcomes. Felodipine is widely available as a generic in the UK at low cost.

Felodipine compared with other calcium channel blockers

Amlodipine and felodipine are the two most commonly prescribed dihydropyridine calcium channel blockers in UK general practice.

Amlodipine has a longer half-life (30 to 50 hours) than felodipine (approximately 11 to 16 hours for the modified-release formulation), which provides a slightly more forgiving pharmacokinetic profile if a dose is missed.

However, amlodipine may cause more pronounced peripheral oedema than felodipine at equivalent blood pressure-lowering doses in some patients.

Felodipine modified-release provides smooth 24-hour blood pressure control and may be preferred in patients who experience troublesome ankle swelling with amlodipine.

Lercanidipine is another option with a potentially lower incidence of peripheral oedema, though it has a smaller evidence base for cardiovascular outcome reduction.

Nifedipine modified-release is an established alternative, particularly in pregnancy-related hypertension where it has a strong safety record.

Your prescriber will select the most appropriate agent based on your clinical profile, other medications, and any previous experience with calcium channel blockers.

Dosage and administration

The recommended starting dose of felodipine for hypertension is 5 mg once daily, taken in the morning.

Your prescriber may increase the dose to 10 mg once daily after 2 to 4 weeks if your blood pressure remains above target.

Elderly patients and patients with liver disease should start at 2.5 mg once daily, with gradual dose increases if needed.

For stable angina, the dosing schedule is the same: 5 mg once daily, increased to 10 mg if necessary to control symptoms.

Always swallow the modified-release tablet whole with a glass of water. Do not crush, chew, or split the tablet.

The modified-release coating is designed to release felodipine slowly over 24 hours.

Breaking the tablet destroys this mechanism, causing the entire dose to be released at once, which may lead to a dangerous drop in blood pressure.

Avoid grapefruit and grapefruit juice throughout treatment. Grapefruit inhibits CYP3A4 in the gut wall, the enzyme responsible for first-pass metabolism of felodipine, and can double or triple the amount of drug that reaches the bloodstream.

Side effects of felodipine

Very common and common side effects

Flushing is the most frequently reported side effect, occurring in up to 1 in 4 patients at higher doses.

It is caused by arterial dilatation and typically manifests as warmth, redness, or a burning sensation in the face and neck.

Flushing usually diminishes within the first two weeks of treatment as the body adjusts.

Headache affects approximately 1 in 10 patients and is also related to vasodilatation. It is usually mild and transient. Paracetamol may be used for relief.

Peripheral oedema (swelling of the ankles, feet, and lower legs) is a class effect of dihydropyridine calcium channel blockers.

It results from increased hydrostatic pressure in capillary beds due to preferential arteriolar dilatation. The swelling is dose-dependent and is not caused by fluid retention or heart failure.

Diuretics are ineffective for this type of oedema.

If ankle swelling is problematic, your prescriber may reduce the dose, add an ACE inhibitor or ARB (which dilate venules and reduce capillary pressure), or switch to an alternative drug.

Dizziness and light-headedness may occur, particularly when standing up quickly (orthostatic hypotension). Rise slowly from sitting or lying positions, especially during the first few days of treatment or after a dose increase.

Uncommon and rare side effects

Uncommon effects include palpitations, tachycardia (fast heartbeat), nausea, abdominal discomfort, and fatigue.

Gingival hyperplasia (overgrowth of the gums) has been reported with long-term use of calcium channel blockers; maintaining thorough oral hygiene and regular dental visits can help reduce this risk.

Rare effects include allergic skin reactions such as rash, pruritus (itching), and urticaria (hives). Very rarely, angioedema, erythema multiforme, photosensitivity, and elevated liver enzymes have been reported.

Seek immediate medical attention if you develop swelling of the face, lips, tongue, or throat, or difficulty breathing.

When to seek urgent medical advice

Contact your GP or call NHS 111 if you experience persistent dizziness, fainting, rapid heartbeat, severe headache, or ankle swelling that significantly affects your daily life.

Call 999 or attend A&E if you develop severe chest pain, signs of a heart attack (crushing chest pain radiating to the arm or jaw, breathlessness, cold sweats), signs of a stroke (facial drooping, arm weakness, speech difficulty), or a severe allergic reaction.

Report any suspected adverse reactions to the MHRA via the Yellow Card scheme at yellowcard.mhra.gov.uk .

Warnings and precautions

Contraindications

Felodipine must not be used in patients with known hypersensitivity to felodipine, other dihydropyridines, or any excipient in the formulation.

It is contraindicated in clinically significant aortic stenosis, unstable angina, acute myocardial infarction (within the first 4 weeks), decompensated heart failure, and haemodynamically significant cardiac outflow obstruction.

Heart failure and cardiac conduction

Although felodipine has minimal negative inotropic effect compared with verapamil and diltiazem, it should be used with caution in patients with impaired left ventricular function.

The V-HeFT III trial showed that felodipine did not worsen outcomes in heart failure, but close monitoring is warranted.

Felodipine does not significantly affect the sinoatrial or atrioventricular nodes and is generally safe to combine with beta-blockers, although blood pressure and heart rate should be monitored.

Grapefruit interaction

This is one of the most clinically significant food-drug interactions in routine practice.

Grapefruit juice can increase felodipine bioavailability by 100 to 200%, leading to excessive hypotension, severe flushing, headache, and tachycardia.

The effect of a single glass of grapefruit juice can last for up to 24 hours. Patients must avoid grapefruit and grapefruit-containing products entirely while taking felodipine.

Drug interactions

Felodipine is metabolised by CYP3A4.

Potent CYP3A4 inhibitors (ketoconazole, itraconazole, erythromycin, clarithromycin, HIV protease inhibitors, and certain antifungals) can substantially increase felodipine plasma levels and should be co-prescribed with caution.

CYP3A4 inducers (phenytoin, carbamazepine, phenobarbital, rifampicin, and St John's wort) can reduce felodipine to sub-therapeutic levels and should be avoided.

The combination of felodipine with ciclosporin may increase levels of both drugs; monitoring is recommended.

Pregnancy and breastfeeding

Felodipine is not recommended during pregnancy. Animal studies have demonstrated reproductive toxicity, including digital abnormalities and reduced foetal weight. There are no adequate controlled studies in pregnant women.

If you become pregnant while taking felodipine, contact your GP immediately. Alternative antihypertensives with established safety in pregnancy include labetalol, methyldopa, and nifedipine modified-release.

Felodipine is excreted in breast milk and should not be used while breastfeeding.

How to get felodipine in the UK

Felodipine is a prescription-only medicine available on the NHS. Your GP can prescribe it following a clinical assessment of your blood pressure or angina symptoms.

Blood pressure monitoring, blood tests (including kidney function and electrolytes), and a cardiovascular risk assessment are typically performed before starting treatment.

Felodipine may be initiated in primary care or by a hospital specialist.

Authorised online prescribers registered with the General Pharmaceutical Council (GPhC) can also prescribe felodipine after an appropriate clinical consultation.

The standard NHS prescription charge in England is currently 9.90 pounds per item; prescriptions are free in Scotland, Wales, and Northern Ireland.

Generic felodipine modified-release tablets are widely available and are cost-effective.

Living with hypertension: lifestyle advice alongside felodipine

Taking felodipine is one component of managing high blood pressure.

NICE recommends a holistic approach that includes dietary changes (reducing salt intake to less than 6 g per day, eating more fruit, vegetables, and wholegrains, and reducing saturated fat), maintaining a healthy weight, exercising for at least 150 minutes per week at moderate intensity, limiting alcohol to no more than 14 units per week, and stopping smoking.

Home blood pressure monitoring can help you and your GP track your response to treatment. Aim for home readings consistently below 135/85 mmHg.

If you have angina, carry your GTN spray at all times and know how to use it.

Attend regular reviews with your GP or practice nurse to assess symptom control, medication adherence, and cardiovascular risk factors.

Report any increase in the frequency or severity of chest pain, as this may indicate disease progression.

Sources

• Felodipine 5 mg Modified-Release Tablets, Summary of Product Characteristics (EMC)
• Felodipine, British National Formulary (BNF)
• NICE NG136: Hypertension in adults: diagnosis and management
• NICE CG126: Stable angina: management
• High blood pressure (hypertension), NHS
• MHRA Yellow Card Scheme