Verapamil

Indications
 Oral
Supraventricular arrhythmias
Adult: As hydrochloride: 120-480 mg daily in 3-4 divided doses according to the severity of the condition and patient's response.
Child: As hydrochloride: <2 yr: 20 mg bid/tid; ≥2 yr: 40-120 mg bid/tid, according to response.
Renal impairment: Use with caution.
Hepatic impairment: Severe: 1/3 of usual dose.
Oral
Angina pectoris
Adult: As hydrochloride: 120 mg tid or 80 mg tid in patients with angina of effort. As modified-release: Up to 480 mg daily.
Renal impairment: Use with caution.
Hepatic impairment: Severe: 1/3 of usual dose.
Oral
Hypertension
Adult: As hydrochloride: 240 mg daily in 2-3 divided doses. Max: 480 mg daily.
Child: As hydrochloride: 10 mg/kg daily in divided doses.
Renal impairment: Use with caution.
Hepatic impairment: Severe: 1/3 of usual dose.
Intravenous
Supraventricular arrhythmias
Adult: As hydrochloride: 5-10 mg injected over 2-3 min, 10 mg may be injected 30 min after the 1st dose, if needed.
Child: As hydrochloride: <1 yr: 100-200 mcg/kg over ≥2 min, repeated after 30 min, if needed; 1-15 yr: 100-300 mcg/kg (max: 5 mg) over ≥2 min , repeated after 30 min, if necessary. Doses to be given under continuous ECG monitoring.
Elderly: As hydrochloride: 5-10 mg injected over ≥3 min, 10 mg may be injected 30 min after the 1st dose, if needed.
Renal impairment: Use with caution.
Hepatic impairment: Severe: 1/3 of usual dose.

Incompatibility: Incompatible with human albumin, amphotericin B, hydralazine hydrochloride, co-trimoxazole, aminophylline, nafcillin sodium, sodium bicarbonate and alkaline solutions. Avoid diluting drug in (1/6)M sodium lactate inj in PVC containers.
Contraindications
 Cardiogenic shock, severe bradycardia, severe left ventricular dysfunction, uncompensated heart failure, hypotension (systolic pressure <90 mm Hg), porphyria. Patients with atrial flutter or atrial fibrillation and an accessory bypass tract (e.g., Wolff-Parkinson-White, Lown-Ganong-Levine syndromes). 2nd or 3rd degree AV block (unless pacemaker is fitted).
Warnings / Precautions
 1st degree AV block. Hypertrophic cardiomyopathy, patients with decreased neuromuscular transmission. Bradycardia or conduction disturbances. Hepatic or renal impairment. For IV admin, verapamil to be given slowly under continuous ECG and BP monitoring. Conventional tablets, extended-release capsules, extended-release core tablets, and controlled extended-release capsules can be admin without regard to food while extended-release tablets to be admin with food. Slower infusion rates (over >3 min) in elderly. Periodic monitoring of LFT during long-term therapy. Avoid sudden withdrawal. Infants and neonates, elderly. Pregnancy and lactation.
Adverse Reactions
 Bradycardia, CHF, MI, AV block, worsening heart failure, transient asystole, hypotension, pulmonary and peripheral oedema, nausea. Constipation, fatigue, hypotension, dizziness, headache, palpitation, flushing, nausea, rashes, alopecia, hyperprolactinaemia, increased LFT and arthralgia.
Potentially Fatal: Heart block and cardiac failure in patients with preexisting cardiac disease. Hepatotoxicity.
Overdose Reactions
 Symptoms: Hypotension, bradycardia, conduction abnormalities, metabolic acidosis, hyperglycaemia, hyperkalaemia, renal dysfunction, seizures, impaired conduction, ECG arrhythmias, changes in mental status, shock and cardiac arrest. Management: Patients to be observed for at least 48 hr (especially if extended-release preparations were ingested) as verapamil may decrease GI transit time. Treatment is symptomatic and supportive. Place the patient in Trendelenburg's position and admin IV fluids. Hypotension may be treated with IV calcium or vasopressor agent. Haemodialysis is unlikely to be useful. If symptoms last for an unusually long time, consider endoscopy.
Drug Interactions
 Increased cardiac depressant effects with β-blockers and flecainide. Increased risk of additive bradycardia, conduction disturbances and digoxin toxicity with digoxin. Increased risk of bradycardia and hypotension with remifentanil and sufentanil. Increased levels of both everolimus and verapamil on concurrent use. May increase doxorubicin, buspirone, carbamazepine, ciclosporin, epirubicin, eplerenone, quinidine, statins, sirolimus, tacrolimus, quinupristin/dalfopristin levels. Verapamil increase blood alcohol levels. Unpredictable interactions with lithium. Decreased verapamil concentrations with phenobarbital, sulfinpyrazone, rifampicin, rifabutin and rifapentine. Increased verapamil concentrations with protease inhibitors and cimetidine.
Potentially Fatal: Increased cardiac depressant effects with amiodarone. Increased risk of QT prolongation with dofetilide, ranolazine, sertindole. Additive bradycardia with ivabradine. Increased risk of heart block with clonidine. Increased risk of acute hyperkalaemia and CV collapse with dantrolene.
See Below for More verapamil Drug Interactions
Food Interactions
 Grapefruit juice increases serum concentration of verapamil by 40%. St John's wort reduces the bioavailability of verapamil.
Mechanism of Actions
 Verapamil inhibits entry of calcium ions into arterial smooth muscle cells as well as the myocytes and conducting tissue. These actions lead to reversal and preventions of coronary artery spasm, reduction in afterload through peripheral vasodilatation and reduction in ventricular rate in patients with chronic atrial flutter or fibrillation and reduction in the occurrence of paroxysmal supraventricular tachycardia. Verapamil reduces BP, relieves angina and slows AV conduction.
Onset: 5 min (IV); 1-2 hr (oral).
Duration:
Absorption: 90% absorbed from GI tract. Bioavailability: 20% (due to extensive first-pass metabolism). Peak plasma concentration: 1-2 hr.
Distribution: Protein-binding: 90%. Crosses placenta and distributed into breast milk.
Metabolism: Extensively metabolised in liver to >12 metabolites. Terminal half-life: 2-8 hr (after single dose); increased to 4.5-12 hr (after repeated doses).
Excretion: Excreted by kidney (70% of dose) as metabolites and via bile into faeces (16%). <4% excreted unchanged.
Administration
 Should be taken with food.
ATC Classification
 C08DA01 - verapamil ; Belongs to the class of phenylalkylamine derivative selective calcium-channel blockers with direct cardiac effects. Used in the treatment of cardiovascular diseases.
Available As
  • Verapamil 120 mg
  • Verapamil 2.5 mg
  • Verapamil 240 mg
  • Verapamil 40 mg
  • Verapamil 5 mg
  • Verapamil 80 mg

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