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When considering the use of diltiazem hydrochloride extended-release (ER), it's important to be aware of certain risks associated with this medication:

Heart Rhythm Concerns: Diltiazem can slow down the heart rate and may lead to heart rhythm issues, such as second- or third-degree atrioventricular (AV) block. Individuals with sick sinus syndrome are particularly susceptible to bradycardia (slow heart rate).

Heart Failure: In some cases, diltiazem has been linked to worsening heart failure. Caution is advised when prescribing this medication to patients with compromised ventricular function.

Low Blood Pressure (Hypotension): The use of diltiazem may result in decreased blood pressure, occasionally leading to symptomatic hypotension. This risk is heightened in patients who are hemodynamically compromised or those taking other medications that lower blood pressure.

Liver Injury: There have been rare reports of significant elevations in liver enzymes and signs of acute liver injury associated with diltiazem use. These reactions typically occur early in the course of therapy and are usually reversible upon discontinuation of the drug.

Severe Skin Reactions: Serious skin conditions, including Stevens-Johnson syndrome, toxic epidermal necrolysis, and exfoliative dermatitis, have been reported in association with diltiazem. If a skin reaction persists, discontinuation of the medication is recommended.

Use During Pregnancy and Breastfeeding: Animal studies have shown that high doses of diltiazem can cause harm to the fetus, including skeletal abnormalities and increased stillbirths. There are no well-controlled studies in pregnant women; therefore, diltiazem should only be used during pregnancy if the potential benefits justify the potential risks. Additionally, diltiazem is excreted in human milk, and its use is not recommended for nursing mothers.

Use in Older Adults: Elderly patients may be more sensitive to the effects of diltiazem due to the greater likelihood of decreased liver, kidney, or heart function, as well as the presence of other medical conditions or concurrent drug therapy. Caution is advised when prescribing diltiazem to older adults, often starting at the lower end of the dosing range.

It's crucial for patients to discuss their full medical history with their healthcare provider before starting diltiazem to ensure its safe use.

Common side effects:

• Dizziness
• Lightheadedness
• Weakness
• Nausea
• Flushing
• Constipation
• Headache

Less common but important to monitor:

• Persistent nausea or vomiting
• Fainting
• Shortness of breath
• Swelling in the ankles or feet
• Unusual tiredness
• Sudden weight gain
• Changes in heartbeat
• Mood changes like depression or agitation
• Unusual dreams
• Severe stomach pain
• Dark urine
• Yellowing of the eyes or skin

Serious side effects:

• Rash
• Itching or swelling especially of the face, tongue, or throat
• Severe dizziness
• Trouble breathing

Interactions with moderate risk that may require dose adjustment, closer monitoring, or timing changes:

• Digoxin
• Fingolimod
• Labetalol
• azole antifungals (such as Ketoconazole)
• Cimetidine
• macrolide antibiotics (such as Erythromycin)
• rifamycins (such as Rifabutin, Rifampin)
• St. John's wort
• Aprepitant/fosaprepitant
• Buspirone
• Colchicine
• elacestrant
• Flibanserin
• Ivabradine
• lomitapide
• certain benzodiazepines (Triazolam, Midazolam)