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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
AF • Rate 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 flutter • Rate 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 HCM • Off-label
•
Start at: 40 mg PO TID
•
Maximum: 480 mg per day
Prevention
Prevention of cluster headache • Off-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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