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Atrial fibrillation - Management
What dose of calcium-channel blocker should I prescribe and how should the dose be titrated?
- Start with a low dose and titrate upwards until atrial fibrillation is controlled.
- Diltiazem (off-label)
- The usual starting dose is 60 mg three times a day (60 mg twice a day in elderly people).
- Maintenance doses range from 60 mg to 180 mg three times a day.
- Once-daily preparations may also be used.
- Verapamil (standard-release)
- The usual starting dose is 40 mg three times a day.
- The maximum dose is 120 mg three times a day.
- Check the person's pulse and blood pressure 1 week after each dose titration to assess response to treatment.
Basis for recommendation
- The dosing information for verapamil is taken from the British National Formulary [BNF 57, 2009].
- Diltiazem is not licensed for treating atrial fibrillation. The recommended doses for diltiazem are based on published US guidelines [Fuster et al, 2006a] and from doses used in clinical trials [Roth et al, 1986; Farshi et al, 1999; Hohnloser et al, 2000].
- CKS expert reviewers agreed with the doses of diltiazem recommended here and suggested that once-daily preparations could be used to improve compliance.
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