ankle edema , is a common adverse effect of l - type calcium channel blocker ( ccb ) and can sometime progress to anasarca . ccb commonly known to cause ankle edema are amlodipine , nifedipine , diltiazem , felodipine , isradipine , lacidipine , lercanidipine , nisoldipine and manidipine . cilnidipine is a 4 generation dihydropyridine ccb approved for the treatment of hypertension with efficacy and safety that is comparable to amlodipine . it is a unique l - type ca channel blocker with an inhibitory action on the sympathetic n - type ca channels . it was introduced in the market , with a claimed superiority over amlodipine . in a study by shetty et al . , therapy with cilnidipine resulted in complete resolution of amlodipine - induced edema in all the cases without significant worsening of hypertension or tachycardia and thus it has been suggested as an alternative antihypertensive for patients with amlodipine - induced edema . although , it was a relatively mild and non - serious adverse effect , it can lead to reduced drug compliance or complete discontinuation of therapy . this was a case report of a 40-year - old male patient , weighing 64 kg was recently diagnosed as a case of uncomplicated hypertension ( stage 1 ) as per jnc 7 guidelines . he was advised to start cilnidipine 5 mg once daily with salt restriction and lifestyle management . he presented with bilateral pitting ankle edema after the 6 week of the drug therapy [ figure 1 ] . clinical examination revealed no symptoms and signs of liver , pulmonary , renal , cardiac and rheumatological disease . all basic investigations such as complete blood count , total lecucocyte count , differential lecucocyte count , erythrocyte sedimentation rate , platelet count , routine urine and stool examination , blood sugar , blood urea , creatinine , liver function test , lipid profile , hr - c - reactive protein , t3 , t4 and thyroid stimulating hormone and serum uric acid were normal . ultrasonography abdomen and pelvic organs and color doppler of lower extremities were also normal . the patient was advised to stop the suspected drug cilnidipine . the patient was changed over to telmisartan with hydrochlorothiazide ( 40 + 12.5 mg ) once day . the edema disappeared completely on the 14 day after stopping cilnidipine with achievement of normotension . thus , the appearance of ankle edema in a patient taking cilndipine could not be explained by a concurrent disease , drug or chemicals while dechallenge improved the condition . common adverse effects reported with cilnidipine are nausea , vomiting , abdominal pain , constipation , dry mouth , gingival hypertrophy , heartburn , headache , dizziness , light headedness and insomnia . rarely , hot flushes , palpitations , ecg abnormalities , chest pain , atrioventricular block , hypersensitivity reactions , photosensitivity , frequent urination and elevated liver enzyme . cilnidipine has been recently suggested to result in complete resolution of amlodipine - induced edema and has been recommended as an alternative antihypertensive for patients with amlodipine - induced edema . however , on the contrary our case presented with bilateral ankle pitting edema with cilnidipine therapy . however , number of mechanisms has been postulated for ccb - induced edema including inhibition of pre - capillary vasoconstriction through arteriolar dilatation and thus , promoting interstitial edema . the structural similarity of clinidipine with other dihydropyridines is hypothesized to be the probable reason for this adverse drug reaction ( adr ) . this adr has  probable  causal relationship with clinidipine as assessed by naranjo score ( score = 6 ) and with world health organization - uppsala monitoring centre scale for causality assessment . the present adr was not studied for dose dependent response and was unpredictable / unusual . thus it is difficult to label it as type - a or b class of adr . the usual approach to patients with ccb - induced edema involves cessation of therapy and substitution with an alternative antihypertensive , typically as a thiazide diuretic or angiotensin - converting enzyme inhibitor ( acei ) or angiotensin receptor blockers ( arbs ) as was carried out in our case . a combination therapy of arbs , diuretic ccb are usual in clinical practice in such cases . the current case report is in contradiction to study of shetty et al . in 27 patients with essential hypertension with amlodipine - induced edema moreover , the present case report leaves another important message for the practicing physicians , that never be first and last to prescribe any new drug . in this case report , the conventional practice to prescribe thiazide diuretic or acei or arbs should be carried until larger clinical trial supports the role of clindipine in such conditions .
cilnidipine is a 4th generation dihydropyridine calcium channel blocker approved recently for the treatment of essential hypertension . 
 it is not known to present with ankle edema like amlodipine . 
 moreover , it has been proposed as an alternative anti - hypertensive for patients with amlodipine - induced edema . 
 we report a case of cilnidipine induced ankle edema .