Dosing & Uses
Dosage Forms & Strengths
tablet/capsule, extended release
- 80 mg PO q8hr initially; usual range: 80-120 mg PO q8hr; not to exceed 480 mg/day
- Covera-HS: 180 mg/day PO at bedtime initially; maintenance: 180-540 mg/day PO at bedtime
- 80 mg PO q8hr initially; maintenance: 80-320 mg PO q12hr
- Calan, Isoptin SR: 180 mg/day PO given in morning (120 mg/day initially if patient elderly or of small stature); for desired response, may be increased to 240 mg/day, then to 360 mg/day (either 180 mg q12hr or 240 mg in morning and 120 mg in evening)
- Verelan: 180 mg/day PO (120 mg/day initially if patient elderly or of small stature); for desired response, may be increased to 240 mg/day PO, then by 120 mg/day at weekly intervals; not to exceed 480 mg/day
- Verelan PM: 200 mg/day PO at bedtime (100 mg/day if patient elderly or of small stature); may be increased by 100 mg/day at weekly intervals as needed; not to exceed 400 mg/day
- Covera-HS: 180 mg/day PO at bedtime (120 mg/day initially if patient elderly or of small stature); for desired response, may be increased to 240 mg/day, then by 120 mg/day at weekly intervals; not to exceed 480 mg/day
Supraventricular Arrhythmia & Atrial Fibrillation/Flutter
2.5-5 mg IV over 2 minutes; 5-10 mg dose may be repeated after 15-30 minutes
Chronic Atrial Fibrillation & Paroxysmal Supraventricular Tachycardia
Treatment of chronic atrial fibrillation (rate control); prevention of paroxysmal supraventricular tachycardia
Immediate release: 240-480 mg/day PO divided q6-8hr
40 mg PO q8hr; may be titrated to 120 mg q8hr
160-320 mg PO q6-8hr
Renal impairment: Use with caution; monitor ECG; for Verelan PM, manufacturer recommends 100 mg at bedtime initially; if CrCl <10 mL/min, reduce dose by 25-50%
Hepatic impairment: In cirrhosis, reduce dose by 20-50% of normal for oral and IV administration
Dosage Forms & Strengths
tablet/capsule, extended release
1-15 years old: 0.1-0.3 mg/kg (not to exceed 5 mg) IV over 2 minutes; second dose (not to exceed 10 mg) may be given after 30 minutes
Alternatively (not well established), 4-8 mg/kg/day PO divided q8hr
In general, lower initial doses are warranted; doses should be adjusted on basis of clinical response
Immediate release: 80 mg PO q8hr initially; usual range: 80-120 mg PO q8hr; not to exceed 480 mg/day
Extended release (Covera-HS): 180 mg PO at bedtime initially; maintenance: 180-540 mg PO at bedtime
Immediate release: 40 mg PO q8hr initially; maintenance: 80-320 mg PO q12hr
Extended release (Calan SR, Isoptin SR, Verelan): 120 mg/day PO given in morning
Extended release (Covera-HS): 180 mg/day PO at bedtime
Extended release (Verelan PM): 100 mg/day PO at bedtime
Serious - Use Alternative
Significant - Monitor Closely
Increased liver enzymes (1%)
Sleep disturbance (1%)
Elevated liver function test results
Hypersensitivity to verapamil or other calcium channel blockers
Congestive heart failure
Sick sinus syndrome (unless permanent pacemaker in place)
2°/3° AV block (unless permanent pacemaker in place)
Atrial fibrillation/flutter with accessory bypass tract
1° AV block
Hypertrophic cardiomyopathy (eg, idiopathic hypertrophic subaortic stenosis)
Hypotension (initially or after dose increases)
Exacerbation of angina (during initiation of treatment, after dose increase, or after withdrawal of beta blocker)
Neuromuscular transmission defects; may exacerbate myasthenia gravis
Hepatic or renal impairment
Persistent progressive dermatologic reactions
Generic products may not be bioequivalent
Do not prescribe Covera-HS or Verelan PM for shift workers
Concurrent beta-blocker therapy
Concurrent ivabradine therapy
Slows AV conduction; use cautiously with beta blockers
Hypotension and bradyarrhythmias observed with concurrent use of other CYP3A4 substrates (eg, cyclosporine, telithromycin) because of competitive metabolism
Coadministration with CYP3A4 inhibitors (eg, erythromycin, itraconazole) may decrease metabolism and thus increase toxicity
Sinus bradycardia resulting in hospitalization and pacemaker insertion has been reported in association with concurrent use of clonidine with verapamil; monitor heart rate if coadministered
Verapamil is no longer part of Pediatric Advanced Life Support tachyarrhythmia algorithm
Potential toxic dose in patients <6 years old: 15 mg/kg
Pregnancy & Lactation
Pregnancy category: C
Lactation: Distributed in milk; nursing infant doses range from <0.01% to 0.1% of mother’s dose; manufacturer suggests refraining from nursing (though American Academy of Pediatrics committee states that drug is compatible with nursing)
A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.
C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.
D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.
X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.
NA:Information not available.
Mechanism of Action
Nondihydropyridine calcium-channel blocker: Inhibits transmembrane influx of extracellular calcium ions across membranes of myocardial cells and vascular smooth muscle cells without changing serum calcium concentrations, resulting in inhibition of cardiac and vascular smooth muscle contraction and thereby dilating main coronary and systemic arteries
Blocks slow inward calcium current responsible for sinus and AV nodal depolarization
Onset: Immediate release, 1-2 hr; IV, 1-5 min
Duration: IV, 10-20 min; PO, 6-8 hr
Peak plasma time: Immediate release, 1-2 hr; extended release, 11 hr (Covera-HS, Verelan PM), 5.21 hr (Calan SR, Isoptin SR), or 7-9 hr (Verelan)
Protein bound: 94%
Vd: 3.8 L/kg
Metabolized by hepatic P450 enzyme CYP3A4
Metabolites: Norverapamil (active)
Half-life: Infants, 4.4-6.9 hr; single dose, 3-7 hr; multiple doses, 4.5 hr; severe hepatic impairment, 14-16 hr
Dialyzable: HD: No
Clearance: 0.5-1 L/hr/kg
Excretion: Urine (70%), feces (9-16%)
Additive: Albumin (human), aminophylline, amphotericin B, floxacillin, hydralazine, trimethoprim/sulfamethoxazole
Y-site: Albumin (human), amphotericin B cholesteryl sulfate, ampicillin, nafcillin, oxacillin, penicillin G, propofol, sodium bicarbonate
Solution: Most common solvents
Additive: Amikacin, amiodarone, ampicillin, ascorbic acid, atropine, bretylium, calcium chloride, calcium gluconate, cefamandole, cefazolin, cefotaxime, cefoxitin, chloramphenicol, cimetidine, clindamycin, dexamethasone, diazepam, digoxin, dobutamine (incompatible at 80 mg in D5W, NS), dopamine, epinephrine, erythromycin, furosemide(?), gentamicin, heparin, hydrocortisone, hydromorphone, insulin, isoproterenol, lidocaine, magnesium sulfate, mannitol, meperidine, metaraminol, methyldopa, methylprednisolone sodium succinate, metoclopramide, morphine, multivitamins, nafcillin(?), naloxone, nitroglycerin, norepinephrine, oxacillin(?), oxytocin, pancuronium, penicillin G, pentobarbital, phenobarbital, phentolamine, phenytoin, piperacillin, potassium chloride, potassium phosphates, procainamide, propranolol, protamine, quinidine, sodium bicarbonate, sodium nitroprusside, theophylline, ticarcillin, tobramycin, tolazoline, vancomycin, vasopressin, vitamins B and C
Syringe: Heparin, inamrinone, milrinone
Y-site: Argatroban, bivalirudin, ciprofloxacin, clarithromycin, dexmedetomidine, dobutamine, dopamine, famotidine, fenoldopam, gatifloxacin, Hextend, hydralazine, inamrinone, linezolid, meperidine, milrinone, penicillin G, piperacillin, ticarcillin
Direct IV over at least 2 minutes (3 minutes in older patients)
IV infusion has been performed
Store at room temperature; protect from light
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