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verapamil (Rx)Brand and Other Names:Isoptin SR, Calan SR, more...Covera HS, Isoptin, Isoptin IV, Calan, Verap, Verapamil SR, Verelan, Verelan PM

 
 
 

Dosing & Uses

AdultPediatricGeriatric

Dosage Forms & Strengths

injectable solution

  • 2.5mg/mL

tablet

  • 40mg
  • 80mg
  • 120mg

tablet/capsule, extended release

  • 100mg
  • 120mg
  • 180mg
  • 200mg
  • 240mg
  • 300mg
  • 360mg
more...

Angina

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/day PO at bedtime initially; maintenance: 180-540 mg/day PO at bedtime

Hypertension

Immediate release

  • 80 mg PO q8hr initially; maintenance: 80-320 mg PO q12hr

Extended release

  • 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

Alternatively, 0.075-0.15 mg/kg (not to exceed 10 mg) IV over 2 minutes; dose may be repeated once 30 minutes after first dose 

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

Tardive Dyskinesia

40 mg PO q8hr; may be titrated to 120 mg q8hr

Migraine (Off-label)

Prophylaxis

160-320 mg PO q6-8hr

Dosing Modifications

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

injectable solution

  • 2.5mg/mL

tablet

  • 40mg
  • 80mg
  • 120mg

tablet/capsule, extended release

  • 100mg
  • 120mg
  • 180mg
  • 200mg
  • 240mg
  • 300mg
  • 360mg
more...

Supraventricular Tachycardia

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

Angina

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

Hypertension

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

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Interactions

Interaction Checker

verapamil and

No Results

     
     activity indicator 
    No Interactions Found
    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

          Minor

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            Adverse Effects

            >10%

            Headache

            Gingival hyperplasia

            1-10%

            Constipation (9%)

            Dizziness (4%)

            Hypotension (4%)

            Dyspepsia (3%)

            Nausea (3%)

            Edema (2%)

            Rash (2%)

            Increased liver enzymes (1%)

            Sleep disturbance (1%)

            Dyspnea

            Postmarketing Reports

            Abnormal ECG

            Hypertension

            Elevated liver function test results

            Asthenia

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            Warnings

            Contraindications

            Hypersensitivity to verapamil or other calcium channel blockers

            Cardiogenic shock

            Congestive heart failure

            Symptomatic hypotension

            Sick sinus syndrome (unless permanent pacemaker in place)

            2°/3° AV block (unless permanent pacemaker in place)

            Cautions

            Aortic stenosis

            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

            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

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            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)

            Pregnancy Categories

            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.

            more...
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            Pharmacology

            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

            Absorption

            Bioavailability: 20-35%

            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)

            Distribution

            Protein bound: 94%

            Vd: 3.8 L/kg

            Metabolism

            Metabolized by hepatic P450 enzyme CYP3A4

            Metabolites: Norverapamil (active)

            Elimination

            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%)

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            Administration

            IV Incompatibilities

            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

            IV Compatibilities

            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

            IV Administration

            Direct IV over at least 2 minutes (3 minutes in older patients)

            IV infusion has been performed

            Storage

            Store at room temperature; protect from light

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            Images

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            Formulary

            FormularyPatient Discounts

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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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