Nifedipine

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Nifedipine on Prescriptsy

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Nifedipine is a calcium channel blocker (CCB) belonging to the dihydropyridine class.

It is one of the most established and widely used cardiovascular medicines in the United Kingdom, prescribed primarily for hypertension (high blood pressure), angina pectoris (chest pain due to coronary artery disease), and Raynaud's phenomenon (episodic vasospasm of the fingers and toes in response to cold or stress).

Nifedipine is available as modified-release (MR) tablets in various strengths and formulations, including branded products such as Adalat Retard, Adalat LA, Coracten, and Fortipine LA.

It is a prescription-only medicine (POM) in the UK and is available on the NHS.

Cardiovascular disease remains the leading cause of death in the UK, and hypertension is the single most important modifiable risk factor for heart attack, stroke, heart failure, and chronic kidney disease.

Approximately one in three adults in England has high blood pressure, and only around half of those diagnosed are treated to target.

Effective blood pressure management with medicines such as nifedipine, combined with lifestyle modifications, can substantially reduce the risk of cardiovascular events.

This page provides a comprehensive clinical overview of nifedipine, including how it works, dosage guidance, side effects, important safety warnings, and how to obtain a prescription in the United Kingdom.

Important safety information about nifedipine

• Nifedipine must be prescribed as a modified-release formulation. Immediate-release nifedipine is associated with serious cardiovascular harm and is no longer recommended for routine clinical use.
• Do not switch between different modified-release brands or formulations without medical guidance, as they are not interchangeable.
• Avoid grapefruit juice while taking nifedipine, as it can significantly increase drug levels and side effects.
• Do not stop nifedipine suddenly. Dose reduction should be gradual under medical supervision.
• Common side effects include headache, flushing, ankle swelling, and dizziness. These often improve with continued use.

Understanding calcium channel blockers

Calcium channel blockers are a class of cardiovascular medicines that work by blocking the entry of calcium ions into cells through voltage-dependent calcium channels.

Calcium is essential for muscle contraction. In blood vessel walls, calcium influx into smooth muscle cells triggers contraction, increasing vascular tone and blood pressure.

By blocking these calcium channels, nifedipine causes vascular smooth muscle to relax, widening the arteries and reducing peripheral vascular resistance.

This lowers blood pressure and improves blood flow to the heart (in angina) and to the extremities (in Raynaud's phenomenon).

Dihydropyridine CCBs (nifedipine, amlodipine, felodipine, lercanidipine) are primarily vascular-selective, meaning they act mainly on arterial smooth muscle with minimal direct effects on the heart.

Non-dihydropyridine CCBs (verapamil, diltiazem) have additional effects on cardiac conduction and heart rate and are used for rate control in atrial fibrillation as well as for hypertension and angina.

Amlodipine has largely replaced nifedipine as the first-line dihydropyridine CCB for hypertension in many practices because of its once-daily dosing and longer half-life, but nifedipine MR remains an important and effective option, particularly for patients who respond well to it, for Raynaud's phenomenon, and for use in pregnancy.

How nifedipine works: mechanism of action

Nifedipine selectively blocks L-type voltage-dependent calcium channels in arterial smooth muscle cells.

These channels normally allow calcium ions to flow into the cell when the membrane is depolarised, triggering a cascade of intracellular events that lead to muscle contraction.

By blocking this calcium influx, nifedipine prevents contraction, causing the smooth muscle to relax.

The result is dilation of systemic arterioles, a reduction in total peripheral vascular resistance, and a decrease in systemic blood pressure.

In the coronary circulation, nifedipine dilates both large epicardial coronary arteries and small coronary arterioles, improving myocardial oxygen delivery.

It also reduces myocardial oxygen demand by lowering afterload (the resistance the heart pumps against).

These combined effects make nifedipine effective in both stable angina and vasospastic (Prinzmetal's) angina, where coronary artery spasm is the primary cause of reduced blood flow.

In Raynaud's phenomenon, nifedipine dilates the small digital arteries in the fingers and toes, improving peripheral blood flow and reducing the frequency and severity of vasospastic episodes.

A Cochrane review found that nifedipine reduces the frequency of Raynaud's attacks by approximately one-third compared with placebo.

Clinical evidence and UK prescribing guidance

The efficacy of nifedipine in hypertension, angina, and Raynaud's phenomenon is supported by extensive clinical trial data.

The ACTION trial (A Coronary disease Trial Investigating Outcome with Nifedipine GITS), which randomised over 7,600 patients with stable angina to nifedipine GITS or placebo on top of standard therapy, demonstrated that nifedipine reduced the need for coronary angiography and coronary interventions, with a good safety profile.

Subgroup analysis showed particular benefit in patients with concomitant hypertension.

NICE guideline NG136 on hypertension in adults recommends calcium channel blockers as step 1 treatment for patients aged 55 and over or of Black African or African-Caribbean family origin, and as step 2 add-on therapy (with an ACE inhibitor or ARB) for other patients.

Amlodipine is the most commonly prescribed dihydropyridine CCB, but nifedipine MR is an appropriate alternative.

The BNF lists nifedipine as an effective option for hypertension, angina, and Raynaud's phenomenon.

For Raynaud's phenomenon, NICE CKS recommends nifedipine MR as first-line pharmacological treatment, starting at a low dose and titrating upwards according to response and tolerability. Treatment is typically given during the autumn and winter months.

Nifedipine compared with other blood pressure medicines

Amlodipine (5 to 10 mg once daily) is the most commonly prescribed dihydropyridine CCB in the UK.

It has a longer half-life than nifedipine (30 to 50 hours versus 2 to 5 hours for nifedipine, though MR formulations extend the effective duration), allowing reliable once-daily dosing without the need for specialised formulations.

However, nifedipine MR is effective and well-established, and some patients tolerate it better or prefer it.

Felodipine and lercanidipine are other dihydropyridine options with slightly different side effect profiles.

ACE inhibitors (ramipril, lisinopril) and angiotensin receptor blockers (losartan, candesartan) are the other major first-line antihypertensive classes.

They are preferred as step 1 in patients under 55 (unless of Black African or Caribbean origin) and work well in combination with CCBs.

Thiazide-like diuretics (indapamide) are step 3 additions. Beta-blockers (atenolol, bisoprolol) are no longer first-line for hypertension but remain important for heart rate control, heart failure, and angina.

Dosage and administration

Always use modified-release nifedipine. The dose depends on the indication and the specific MR formulation.

For hypertension, a common starting dose is 10 mg or 20 mg twice daily (for 12-hour MR products) or 30 mg once daily (for 24-hour MR products).

The dose may be increased in steps of 10 mg every 1 to 2 weeks, up to a maximum of 90 mg daily, according to blood pressure response.

For angina, the dose range is similar. For Raynaud's phenomenon, start at the lowest dose (5 mg or 10 mg twice daily) and increase gradually as tolerated.

Swallow MR tablets whole with water. Do not crush, chew, or break them. Take with or after food. Avoid grapefruit and grapefruit juice throughout treatment.

If you miss a dose, take it as soon as you remember unless it is nearly time for the next dose; do not double up.

Do not stop nifedipine abruptly; taper the dose gradually over 1 to 2 weeks if discontinuation is required.

Side effects of nifedipine

Common side effects

The most frequently reported side effects are headache, flushing, dizziness, palpitations, and peripheral oedema (ankle swelling).

These are direct consequences of vasodilation and are most noticeable when starting treatment or increasing the dose. Headache and flushing typically improve within 1 to 2 weeks.

Peripheral oedema is dose-dependent and results from arteriolar dilation (not fluid retention), so it does not respond well to diuretics.

Combining nifedipine with an ACE inhibitor or ARB can help reduce oedema by restoring venous-arteriolar balance.

Other side effects

Constipation, nausea, and abdominal discomfort may occur. Gingival hyperplasia (gum overgrowth) has been reported with long-term CCB use; good dental hygiene reduces the risk.

Uncommon effects include tachycardia, sleep disturbance, tremor, visual disturbance, rash, muscle cramps, and urinary frequency.

Rare adverse effects include paradoxical angina (typically with immediate-release formulations), gynaecomastia, elevated liver enzymes, and photosensitivity.

When to seek urgent medical advice

Contact your GP or call NHS 111 if you experience persistent headache, significant ankle swelling, rapid heartbeat, or dizziness that does not improve.

Call 999 if you develop severe chest pain, sudden weakness or numbness on one side of the body, difficulty speaking, or severe breathlessness, as these may indicate a heart attack or stroke.

Report suspected adverse reactions to the MHRA at yellowcard.mhra.gov.uk .

Warnings and precautions

Contraindications

Nifedipine is contraindicated in cardiogenic shock, clinically significant aortic stenosis, unstable angina, within 4 weeks of a myocardial infarction, in combination with rifampicin, and in patients with known hypersensitivity to nifedipine or other dihydropyridines.

Formulation safety

Only modified-release formulations should be used.

Immediate-release nifedipine capsules have been associated with serious cardiovascular events, including stroke and myocardial infarction, due to rapid, unpredictable blood pressure drops and reflex sympathetic activation.

The MHRA and BNF advise against their use for hypertension and angina. Furthermore, different modified-release products are not interchangeable; patients should be maintained on the same brand.

Drug interactions

CYP3A4 inhibitors (ketoconazole, itraconazole, erythromycin, clarithromycin, diltiazem, verapamil, ritonavir, grapefruit juice) increase nifedipine plasma levels. CYP3A4 inducers (rifampicin, carbamazepine, phenytoin, phenobarbital, St John's wort) reduce nifedipine levels.

Concurrent beta-blocker use is common and generally safe but requires monitoring. Nifedipine may increase digoxin levels.

Additive hypotension may occur with other antihypertensives, nitrates, or PDE5 inhibitors (sildenafil, tadalafil).

Pregnancy and breastfeeding

Nifedipine is one of the preferred antihypertensive agents in pregnancy and is widely used for pregnancy-induced hypertension and pre-eclampsia. It is also used off-label as a tocolytic.

It crosses the placenta and should be used under specialist supervision.

Nifedipine is excreted in breast milk in small amounts; breastfeeding is generally considered acceptable, but discuss with your prescriber.

How to get nifedipine in the UK

Nifedipine is a prescription-only medicine available through the NHS.

You can obtain a prescription from your GP, a hospital specialist, or an authorised online prescriber registered with the GPhC.

The standard NHS prescription charge of 9.90 pounds applies in England; prescriptions are free in Scotland, Wales, and Northern Ireland.

Your prescriber will specify the exact brand and formulation to ensure consistency.

Lifestyle advice for managing blood pressure

Lifestyle modifications are an essential part of managing hypertension alongside medication.

NICE recommends reducing salt intake to less than 6 g per day, eating a balanced diet rich in fruit, vegetables, and whole grains, maintaining a healthy weight (BMI 18.5 to 24.9), exercising regularly (at least 150 minutes of moderate activity per week), limiting alcohol to 14 units per week, stopping smoking, and managing stress.

These measures can enhance the blood-pressure-lowering effect of nifedipine and reduce overall cardiovascular risk.

Sources

• Adalat Retard, Summary of Product Characteristics (EMC)
• Nifedipine, British National Formulary (BNF)
• Hypertension in adults, NICE Guideline NG136
• Nifedipine, NHS
• MHRA Yellow Card Scheme