Your patient has swollen ankles linked with the use of calcium channel blockers…

A: Ankle oedema is a common and often troublesome adverse effect of calcium-channel blocker (CCB) treatment that can affect adherence. Because CCB-associated ankle oedema is caused by changes in capillary pressure leading to leakage into interstitial areas, rather than due to water retention, it is usually refractory to diuretic treatment.¹ Treatment strategies include:

• Non-pharmacological methods — elevation of legs when in a prone position, or the use of graduated compression stockings, may be an option for some patients with mild oedema; however, there is little evidence to suggest these methods are effective
  
• Dose adjustments — reducing the dosage of a CCB may reduce the severity of ankle oedema
  
• Switching CCB — switching from a dihydropyridine CCB to a nondihydropyridine CCB (or vice versa) may reduce ankle oedema, although current evidence on the success rates of this strategy is conflicting
  
• Diuretics — unlike for other types of oedema, loop and thiazide diuretics appear to have little effect on CCB induced oedema
  
• Angiotensin-converting enzyme inhibitors (ACEI) — adding an ACEI to treatment with a CCB has been shown to reduce the incidence of ankle oedema in several studies; the mechanism for this is unknown
  
• Angiotensin-II receptor blockers (ARBs) — like ACEIs, ARBs can reduce CCB-induced ankle oedema, but the mechanism is unknown
  
• Nitrates — Nitrates may offer some benefit for treating CCB-induced ankle oedema, but the need for a nitrate-free period poses practical challenges
  
• Discontinuation — a CCB may need to be stopped if the management strategies outlined above fail