Diltiazem with beta-blocker — GPhC CRA MCQ
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Correct answer: D — Defer diltiazem pending review of combined nodal blockade
Defer diltiazem pending review of combined nodal blockade: The low pulse and dizziness may already reflect clinically important rate suppression; adding a rate-limiting calcium-channel blocker to a beta blocker can precipitate symptomatic bradycardia or heart block. Supply diltiazem and check blood pressure after seven days: Blood-pressure monitoring alone would miss the immediate conduction risk suggested by the existing pulse and symptoms. Supply half-dose diltiazem pending routine clinical review: An unauthorised dose change does not resolve whether the combination is appropriate in a symptomatic bradycardic patient. Stop bisoprolol immediately and supply prescribed diltiazem: Abruptly changing established cardiac treatment without clarifying the indication and prescriber plan is unsafe. Supply both medicines with doses separated by twelve hours: Temporal separation does not remove their overlapping effects on sinus and atrioventricular-node conduction.
Reference: BNF: diltiazem hydrochloride: https://bnf.nice.org.uk/drugs/diltiazem-hydrochloride/; BNF: bisoprolol fumarate: https://bnf.nice.org.uk/drugs/bisoprolol-fumarate/