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Author Topic: Anti-proteinuric effects of certain meds
Posts: 18
Post Anti-proteinuric effects of certain meds
on: May 17, 2011, 15:07

We have so many patients on norvasc. If the heart rate is not low, wouldn’t it be best to try verpamil or diltiazem? Especially if the patient is spilling protein and has some ankle edema?

Is there some reason to not prescribe these?

How about the patient who has a cardiac history, an old CABG but is now stable and a few years out?

Nurse Practitioner

Posts: 18
Post Re: Anti-proteinuric effects of certain meds
on: May 17, 2011, 15:09

Yes. non-dihydropyridines like diltiazem and verapamil have greater anti-proteinuric effects than dihydropyridines (norvasc). most physicians stay away from verapamil, however, because it has extensive AV-nodal blocking effects. Thus, the therapeutic window is small and patients can easily find themselves suffering from symptomatic bradycardia. I'm not sure if this "fear" has been proven in the scientific literature, but it certainly has been seen anectodally.

Diltiazem would be an excellent choice because it provides the added anti-proteinuric effects w/o the significant AV-nodal blocking effect. It has a better therapeutic window in this regard.

Here's a nice review article comparing the anti-proteinuric effects of CCB's: KI 1998 p. 1559. Focus on Figure 3: the high albuminuria portion of the graph: non-dihydropyridines have a greater anitproteinuric effect than dihydropyridines, and in some cases, to the same degree as ACE-inhibitors!

Speaking to the cardiac patient: patients with cardiac histories should be on beta-blockers. Compared to non-dihydropyridines, beta-blockers have been shown to decrease mortality and other cardiac events. As a result, the proteinuric patient with a cardiac history will rarely be given diltiazem or verapamil because of the maximum beta-blockade that is necessary to prolong survival.

Tejas Desai, MD
Division of Nephrology and Hypertension
East Carolina University - Brody School of Medicine

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