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Verapamil

Oral
Intravenous
Class
Antiarrhythmics
Subclass
Nondihydropyridine calcium channel blockers
Substance name
Verapamil hydrochloride
Common formulations
Tablet
See also
Verapamil ER (Verelan PM®)
Verapamil SR (Verelan®, Calan SR®)
Verapamil DR (Verelan®)
Verapamil COER (Covera-HS®)
Dosage and administration
Adults patients
Treatment
AFRate control
240-320 mg PO daily, in 3-4 divided doses
Angina pectoris
80-120 mg PO TID
Consider starting with 40 mg TID in patients with an increased response to verapamil, such as the elderly or low-weight patients. Titrate at daily intervals based on response.
Atrial flutterRate control
240-320 mg PO daily, in 3-4 divided doses
Hypertension
Start at: 80 mg PO TID
Maintenance: 80-120 mg PO TID
Maximum: 480 mg per day
Consider starting with 40 mg TID in patients with an increased response to verapamil, such as the elderly or low-weight patients. Titrate at weekly intervals based on response.
Stable angina
80-120 mg PO TID
Consider starting with 40 mg TID in patients with an increased response to verapamil, such as the elderly or low-weight patients. Titrate at weekly intervals based on response.
Vasospastic angina
80-120 mg PO TID
Consider starting with 40 mg TID in patients with an increased response to verapamil, such as the elderly or low-weight patients. Titrate at weekly intervals based on response.
LVOTO in patients with HCMOff-label
Start at: 40 mg PO TID
Maximum: 480 mg per day
Prevention
Prevention of cluster headacheOff-label
Start at: 80 mg PO TID
Maintenance: 240-360 mg PO daily, in 3-4 divided doses
Maximum: 720 mg per day
Secondary prevention
Secondary prevention of paroxysmal SVT
240-480 mg PO daily, in 3-4 divided doses
Other off-label uses
Treatment of nocturnal leg cramps
Indications for use
Labeled indications
Adults
Treatment of angina pectoris
Treatment of AF (rate control)
Treatment of atrial flutter (rate control)
Treatment of hypertension
Treatment of stable angina
Treatment of vasospastic angina
Secondary prevention of paroxysmal SVT
Off-label indications
Adults
Treatment of LVOTO in patients with HCM
Treatment of nocturnal leg cramps
Prevention of cluster headache
Safety risks
Contraindications
Hypersensitivity to verapamil or its components
Hypotension or cardiogenic shock
Second- or third-degree AV block
Do not use verapamil in patients with second- or third-degree AV block except in the presence of a functioning ventricular pacemaker.
Severe LV dysfunction
Sick sinus syndrome
Do not use verapamil in patients with sick sinus syndrome except in the presence of a functioning ventricular pacemaker.
WPW syndrome or Lown-Ganong-Levine syndrome
Do not use verapamil in patients with AF or atrial flutter associated with an accessory bypass tract, such as in WPW syndrome or Lown-Ganong-Levine syndrome.
Warnings and precautions
Drug-induced liver injury
Maintain a high level of suspicion, as verapamil may cause acute liver injury with elevations in liver enzymes.
Pulmonary edema
Use caution in patients with HCM.
Specific populations
Renal impairment
eGFR 0-90 mL/min/1.73 m²
Use with caution. Monitor blood pressure. Monitor heart rate. Monitor PR interval.
Renal replacement therapy
Continuous renal replacement
Use with caution. Monitor blood pressure. Monitor heart rate. Monitor PR interval.
Intermittent hemodialysis
Use with caution. Monitor blood pressure. Monitor heart rate. Monitor PR interval.
Peritoneal dialysis
Use with caution. Monitor blood pressure. Monitor heart rate. Monitor PR interval.
Hepatic impairment
Child-Pugh A (mild)
Use with caution. Monitor blood pressure. Monitor heart rate. Monitor PR interval.
Child-Pugh B (moderate)
Use with caution. Monitor blood pressure. Monitor heart rate. Monitor PR interval.
Child-Pugh C (severe)
Use with caution. Reduce dose by 70%. Monitor blood pressure. Monitor heart rate. Monitor PR interval.
Pregnancy and breastfeeding
Pregnancy
All trimesters • Australia Category: C
Use only if clearly needed. Evidence of fetal harm in animals. Consider safer alternatives for hypertension in pregnancy.
Breastfeeding
Halt breastfeeding temporarily.
Low excretion in breastmilk (5-25%).
Undetectable levels in breastfed infants.
May potentially cause adverse effects in breastfed infants.
No overt adverse effects on lactation reported.
Adverse reactions
Very common > 10%
Bradycardia
Common 1-10%
AV block, skin rash, congestive heart failure, pulmonary edema, hypotension, peripheral edema, constipation, dizziness, dyspnea, fatigue, headache, nausea
Uncommon < 1%
Myocardial infarction, stroke, Stevens-Johnson syndrome, angina pectoris, chest pain, claudication, palpitations, purpura, syncope, diarrhea, swollen gums, dry mouth, ecchymosis, confusion, incoordination, insomnia, paresthesia, muscle cramps, psychosis, shaking, somnolence, extrapyramidal signs, arthralgia, hair loss, hyperkeratosis, skin macules, sweating, urticaria, erythema multiforme, blurred vision, tinnitus, gynecomastia, galactorrhea, ↑ serum prolactin, urinary frequency, intermenstrual bleeding, erectile dysfunction, skin flushing
Interactions
Drug(s)
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