verapamil hydrochloride

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verapamil hydrochloride

Pharmacologic class: Calcium channel blocker

Therapeutic class: Antianginal, antiarrhythmic (class IV), antihypertensive

Pregnancy risk category C

Action

Decreases conduction of sinoatrial and atrioventricular (AV) nodes by inhibiting calcium influx into cardiac and vascular smooth muscle cells, inhibiting excitatory contraction. These effects prolong AV node refractoriness and decrease myocardial oxygen consumption.

Availability

Capsules (extended-release): 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg

Capsules (sustained-release): 120 mg, 180 mg, 240 mg, 360 mg

Injection: 2.5 mg/ml in 2- and 4-ml vials, ampules, and syringes

Tablets (extended-release): 120 mg, 180 mg, 240 mg

Tablets (immediate-release): 40 mg, 80 mg, 120 mg

Indications and dosages

Angina

Adults: Initially, 80 mg (immediate-release) P.O. t.i.d.; may titrate at daily or weekly intervals to 360 mg/day. Or initially, 180 mg (extended-release) P.O. once daily at bedtime, titrated up to 480 mg/day at bedtime.

Supraventricular tachyarrhythmias (SVTs)

Adults: 5 to 10 mg (0.075 to 0.15 mg/kg) I.V. bolus over 2 minutes; may give additional 10 mg after 30 minutes if response inadequate. Or 240 to 480 mg (immediate-release) P.O. daily in three or four divided doses.

To control ventricular rate in chronic atrial flutter or atrial fibrillation in patients receiving digoxin

Adults: 240 to 320 mg P.O. daily in three or four divided doses

Hypertension

Adults: Initially, 180 mg (extended-release tablet) or 200 mg (extended-release capsule) P.O. daily at bedtime. For maintenance, may titrate up to 480 mg (extended-release tablet) or 400 mg (extended-release capsule) P.O. daily at bedtime. Or initially, 80 mg (immediate-release tablet) P.O. t.i.d.; may titrate at daily or weekly intervals up to 360 to 480 mg/day. Or initially, 240 mg (sustained-release capsule) P.O. q day in morning; for maintenance, may titrate up to 240 mg P.O. b.i.d. or 480 mg P.O. once daily in morning. Titrate based on response.

Dosage adjustment

• Renal or hepatic impairment
• Concurrent digoxin therapy

Off-label uses

• Ventricular tachycardia
• Migraine headache prophylaxis
• Neurogenic bladder
• Premature labor

Contraindications

• Hypersensitivity to drug or other calcium channel blockers
• Sick sinus syndrome
• Second- or third-degree AV block (except in patients with artificial pacemakers)
• Hypotension
• Heart failure, severe ventricular dysfunction, or cardiogenic shock (except when associated with SVTs)
• Atrial flutter or atrial fibrillation associated with accessory bypass tracts (such as Wolff-Parkinson-White or Lown-Ganong-Levine syndrome)

Precautions

Use cautiously in:
• renal or severe hepatic impairment; first-degree AV block; idiopathic hypertrophic cardiomyopathy; neuromuscular transmission defects (such as Duchenne's muscular dystrophy); respiratory depression; digital ulcers, ischemia, or gangrene
• elderly patients
• pregnant or breastfeeding patients.

Administration

• Give I.V. over at least 2 minutes.
• Discontinue disopyramide 48 hours before starting verapamil. Don't restart disopyramide for at least 24 hours after verapamil therapy ends.

Adverse reactions

CNS: anxiety, confusion, dizziness, syncope, drowsiness, headache, jitteriness, abnormal dreams, disturbed equilibrium, psychiatric disturbances, asthenia, paresthesia, tremor, fatigue

CV: chest pain, hypotension, palpitations, peripheral edema, tachycardia, arrhythmias, heart failure, bradycardia, AV block

EENT: blurred vision, epistaxis, tinnitus

GI: nausea, vomiting, diarrhea, constipation, dyspepsia, dry mouth, anorexia

GU: dysuria, urinary frequency, nocturia, polyuria, sexual dysfunction, gynecomastia

Hematologic: anemia, leukopenia, thrombocytopenia

Metabolic: hyperglycemia

Musculoskeletal: joint stiffness, muscle cramps

Respiratory: cough, dyspnea, shortness of breath, pulmonary edema

Skin: dermatitis, flushing, diaphoresis, photosensitivity, pruritus, urticaria, rash, erythema multiforme, Stevens-Johnson syndrome

Other: gingival hyperplasia, edema, weight gain

Interactions

Drug-drug.Antihypertensives: additive hypotension

Aspirin: increased risk of bleeding

Beta-adrenergic blockers, other antiarrhythmics: additive adverse cardiovascular reactions

Carbamazepine, cyclosporine: increased blood levels of these drugs

CYP450-3A4 inducers (such as rifampin): decreased verapamil blood level

CYP450-3A4 inhibitors (such as erythromycin, ritonavir): increased verapamil blood level

Digoxin: increased digoxin blood level, greater risk of toxicity

Lithium: increased or decreased lithium blood level

Neuromuscular blockers (succinylcholine, tubocurarine, vecuronium): prolonged neuromuscular blockade

Theophylline: decreased verapamil clearance, increased blood level, and possible toxicity

Drug-diagnostic tests.Alanine aminotransferase, alkaline phosphatase, aspartate aminotransferase, blood urea nitrogen, glucose, lactate dehydrogenase: increased levels

Granulocytes: decreased count

Drug-food.Coffee, tea: increased caffeine blood level

Grapefruit juice: increased verapamil blood level and effects

Drug-herbs.Black catechu: increased drug effects

Cola nut, guarana: increased caffeine blood level

Ephedra (ma huang), St. John's wort: reduced hypotensive effect of verapamil

Yerba maté: decreased clearance of this herb

Drug-behaviors.Alcohol use: additive hypotension

Patient monitoring

• With I.V. use, monitor vital signs and ECG continuously.
• Assess blood pressure when therapy begins and when dosage is adjusted.
• Watch closely for signs and symptoms of heart failure.

Monitor for signs and symptoms of erythema multiforme (fever, rash, sore throat, mouth sores, cough, iris lesions). Report early indications immediately, before condition can progress to Stevens-Johnson syndrome.
• Assess CBC. Watch for blood dyscrasias.
• Monitor blood glucose level. Stay alert for hyperglycemia in diabetic patients.

Patient teaching

• Instruct patient to avoid chewing, breaking, or crushing extended-release form.

Advise patient to immediately report rash, unusual bleeding or bruising, fainting, and (in long-term use) fatigue, nausea, or yellowing of skin or eyes.
• Caution patient not to take with grapefruit juice.
• Instruct patient to limit caffeine intake and avoid alcohol.
• Advise patient to seek medical advice before using over-the-counter medications or herbs.
• Tell patient to avoid sun exposure and to wear sunscreen and protective clothing when going outdoors.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, herbs, and behaviors mentioned above.

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References in periodicals archive ?
Last month, Searle, the pharmaceutical arm of Monsanto - began marketing its recently approved drug, Covera-HS, for high blood pressure and the chest pain of angina.
10 /PRNewswire/ -- In a large study of angina patients featured today at the 70th Scientific Sessions of the American Heart Association, Covera-HS (COER verapamil hydrochloride), a chronotherapeutic treatment for hypertension and angina, was shown to provide efficacy comparable to the standard of care in treating chronic stable angina.
and Canada, is the first to compare Covera-HS, a drug given at bedtime to control early-morning surges in blood pressure and heart rate, with conventional anti-anginal therapy given in the morning.
An 8-week prospective, multi-center, randomized, double-blind study of 257 patients (64 nondippers and 193 dippers) using the first chronotherapeutic treatment for hypertension and angina, Covera-HS (COER-verapamil hydrochloride), shows that this medication can reduce nocturnal blood pressure in nondippers an average of -10/-8 mmHg (systolic/diastolic).
White's team concluded that part of the change in nocturnal blood pressure on patients taking Covera-HS was due to this phenomenon.
of Covera-HS is delivered in the early waking hours when blood pressure
The unique features of Covera-HS will be further compared to the
Available in both 180 mg and 240 mg tablets, Covera-HS is designed for oral dosing at bedtime.
In two double-blind, randomized, placebo-controlled studies of 382 total patients with mild to moderate hypertension, clinically significant 24-hour blood pressure control was demonstrated with once- daily, evening doses of Covera-HS (180 mg/day to 540 mg/day), with peak effects between 6 a.
Upon final marketing clearance from the FDA, Covera-HS will be marketed by Searle and manufactured by ALZA, and ALZA will receive royalties based on sales of the product.
Taken at bedtime, Covera-HS is designed to lower blood pressure by releasing active drug in concert with the body's natural circadian rhythms.