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Calcium antagonists in the elderly. A risk-benefit analysis
1Division of Geriatric Medicine, Northwestern University Medical School, Chicago, Illinois, USA. jbs157@nwu.edu
Insights
Calcium antagonists effectively manage blood pressure and angina in patients of all ages. However, aging reduces drug clearance, potentially increasing adverse effects and necessitating dosage adjustments in older adults.
Area of Science:
- Cardiology
- Pharmacology
- Geriatrics
Background:
- Calcium antagonists are widely used for hypertension and angina.
- Aging affects drug clearance and patient sensitivity to medications.
- Dosage standardization across age groups in clinical trials complicates sensitivity analysis.
Purpose of the Study:
- To evaluate the efficacy and safety of calcium antagonists in older versus younger patients.
- To identify age-related differences in calcium antagonist pharmacokinetics and pharmacodynamics.
- To inform optimal therapeutic strategies for elderly individuals.
Main Methods:
- Review of clinical trials comparing calcium antagonist efficacy and safety in different age groups.
- Analysis of pharmacokinetic data regarding drug clearance in aging populations.
- Comparison of blood pressure and heart rate responses to standard dosages.
Main Results:
- Reduced drug clearance with aging necessitates dosage adjustments.
- Older patients exhibit greater blood pressure reduction and heart rate suppression.
- Verapamil, but not dihydropyridines, reduced mortality post-myocardial infarction.
- Increased risk of adverse effects and drug interactions in the elderly.
Conclusions:
- Calcium antagonists require careful dosing in older adults due to altered pharmacokinetics.
- While beneficial for symptoms, long-term benefits in elderly hypertension are unproven.
- Verapamil shows specific mortality benefits post-myocardial infarction.
- Elderly patients face higher risks of adverse events and interactions.
Abstract:
Calcium antagonists are effective in lowering blood pressure, relieving anginal symptoms and improving exercise tolerance in older and younger patients with coronary artery disease. Verapamil and diltiazem are effective in slowing ventricular response rates to supraventricular arrhythmias in both older and younger patients. Although they belong to at least 3 distinct chemical classes, a moderate decrease in the clearance of all calcium antagonists occurs with aging. Most clinical trials of these drugs have used the same dosages in older and younger patients, confounding analyses of sensitivity in older compared with younger patients. Greater reductions in blood pressure usually occur in older compared with younger patients receiving the same dosages of calcium antagonists; similarly, the dosage required to reduce blood pressure to a certain level is usually lower in older compared with younger patients. Drug acquisition costs are generally higher for calcium antagonists than for beta-blockers or diuretics. Compared with younger patients, greater heart rate suppression may be seen in older patients treated with verapamil and diltiazem; conversely, heart rate increases are usually seen with dihydropyridines. Calcium antagonists have not been shown to provide long-term benefits or decreased morbidity or mortality in elderly patients with hypertension. Verapamil, but not dihydropyridines, decreases mortality after myocardial infarction in patients without congestive heart failure. Calcium antagonists have not been shown to be beneficial in the treatment of acute stroke. Adverse effects, such as a postural hypotension, may be more frequent in elderly compared with younger patients. In addition, the elderly are at greater risk for drug interactions with calcium antagonists due to the higher likelihood that they are receiving other drugs.