Confirmation

Are you sure you want to sign out?

Sign Out Cancel

Clinical Practice Guidelines
Drug Monographs
Clinical Resources
BCEHS Handbook FAQ
About BCEHS Handbook
Licence Level Filtering

PCP ACP CCP EMR DISPATCH

Open All

Verapamil

Classification

Non-dihydropyridine calcium channel blocker, Antianginal Agent, Antiarrhythmic Agent

Indications

CCP: Angina, NSTEMI, STEMI

CCP: Hypertension

CCP: Atrial fibrillation, atrial flutter; rate control

Contraindications

Hypersensitivity
Severe left ventricular dysfunction
Hypotension (systolic pressure <90 mm Hg) or cardiogenic shock
Sick sinus syndrome (except in patients with a functioning artificial ventricular pacemaker)
Second- or third-degree atrioventricular (AV) block (except in patients with a functioning artificial ventricular pacemaker)
Atrial flutter or fibrillation and an accessory pathway (Wolff-Parkinson-White [WPW] syndrome, Lown-Ganong-Levine syndrome).
Complicated myocardial infarction (MI) (ventricular failure manifested by pulmonary congestion)
Marked bradycardia
Concurrent use of ivabradine or flibanserin
Concurrent use of IV beta-blocking agents
Contraindicated in infants

Adult dosages

CCP: Acute coronary syndrome

80-120 mg PO tid max daily dose 480 mg/day

CCP: A-fib/flutter (rate control)

Do not use in patients with preexcitation associated with an accessory pathway.

Initial: 5-10 mg IV bolus over 2 minutes may be repeated in 15-30 minutes.
Maintenance: 5 mg/hr continuous IV infusion titrate to effect. Max dose 20 mg/hour.

CCP: Hypertension

40-80 mg tid PO to a max dose 480 mg/day (immediate release)
120-180 mg od PO (extended release)

Pediatric Considerations And Dosing

CCP: Supraventricular tachycardia

Children 1-15
- 0.1-0.3 mg/kg/dose IV to a max of 5 mg/dose
- May repeat in 15-30 minutes to a max dose of 10 mg/dose
Adolescents
- 0.1-0.3 mg/kg/dose IV to a max of 5 mg/dose
- May repeat in 15-30 minutes to a max dose of 10 mg/dose

Mechanism Of Action

Inhibits calcium ions from entering the select voltage-sensitive areas of vascular smooth muscle and myocardium during depolarization. This slows automaticity and conduction of AV node. Verapamil also produces relaxation of coronary vascular smooth muscle and coronary vasodilation. This subsequent vasodilation increases myocardial oxygen delivery in patients with vasospastic angina.

Pharmocokinetics

Onset: 1-2 hours oral 3-5 minutes IV

Duration: 6-8 hours oral 0.5-6 hours IV

Half-life: 2-5 hours

Adverse Effects

Nervous system:

Headache
Balance impairment, confusion, dizziness, drowsiness, extrapyramidal reaction, fatigue, insomnia, lethargy, paresthesia, psychosis, shakiness, sleep disorder

Cardiovascular

Acute myocardial infarction, angina pectoris, ankle edema, atrioventricular block, atrioventricular dissociation, bradycardia, cardiac failure, cerebrovascular accident, chest pain, claudication, ECG abnormality, edema, hypotension, palpitations, peripheral edema, syncope, tachycardia
Asystole, flushing, ventricular tachycardia

Dermatologic

Alopecia, diaphoresis, ecchymoses, erythema multiforme, hyperkeratosis, macular eruption, skin rash, Stevens-Johnson syndrome, urticaria

Endocrine & metabolic

Galactorrhea not associated with childbirth, gynecomastia, hyperprolactinemia, spotty menstruation

Gastrointestinal

Constipation, diarrhea, dyspepsia, gastrointestinal distress, gingival hyperplasia, nausea, xerostomia

Genitourinary

Impotence

Hematologic & oncologic

Bruise, purpuric vasculitis

Hepatic:

Increased serum transaminases

Neuromuscular & skeletal

Arthralgia, asthenia, muscle cramps, myalgia

Ophthalmic

Blurred vision, Rotary nystagmus

Optic

Tinnitus

Renal:

Polyuria

Respiratory

Dyspnea, flu-like symptoms, pulmonary edema, respiratory failure

Warning And Precautions

May cause first-degree atrioventricular (AV) block or sinus bradycardia. Higher degrees of AV block may also occur (rare) and, in extreme cases, asystole; more likely to occur in patients with a sick sinus syndrome.
Elevations of hepatic transaminases, alkaline phosphatase, and bilirubin have been reported.
During an episode of atrial fibrillation or flutter in patients with an accessory pathway or preexcitation syndrome, use has been associated with increased anterograde conduction down the accessory pathway leading to ventricular fibrillation.
Considered contraindicated in patients with wide complex tachycardias unless known to be supraventricular in origin.
Decreased neuromuscular transmission has been reported; use with caution in patients with attenuated neuromuscular transmission.
IV verapamil has increased intracranial pressure in patients with supratentorial tumors at the time of anesthesia induction; use with caution in these patients.
Use with caution in left ventricular dysfunction; due to negative inotropic effects, may exacerbate condition.
Use with caution in patients with renal impairment, monitor hemodynamics and ECG in severe impairment, particularly if concomitant hepatic impairment. Avoid repeated injections of IV verapamil in patients with significant renal failure.

Drug Interactions

Abametapir
Abemaciclib
Acalabrutinib
Afatinib
Alcohol (Ethyl)
Alfentanil
Alfuzosin
Alfuzosin
Aliskiren
Alitretinoin (Systemic)
Alpha1-Blockers
ALPRAZolam
Amifostine
Amiodarone
AmLODIPine
Amphetamines
Antipsychotic Agents (Second Generation [Atypical])
Apixaban
Aprepitant
ARIPiprazole
ARIPiprazole Lauroxil
Aspirin
Astemizole
Asunaprevir
AtorvaSTATin
Atosiban
Avanafil
Avapritinib
Axitinib
Barbiturates
Barnidipine
Bedaquiline
Benidipine
Benperidol
Benzhydrocodone
Berotralstat
Betrixaban
Bilastine
Blonanserin
Bortezomib
Bosutinib
Bradycardia-Causing Agents
Brexpiprazole
Brigatinib
Brimonidine (Topical)
Bromocriptine
Bromperidol
Budesonide (Oral Inhalation)
Budesonide (Systemic)
Budesonide (Topical)
Buprenorphine
BusPIRone
Cabozantinib
Calcium Salts
Cannabis
CarBAMazepine
Cardiac Glycosides
Cariprazine
Celiprolol
Ceritinib
Cilostazol
Cimetidine
Cisapride
Clindamycin (Systemic)
Clofazimine
Clopidogrel
CloZAPine
Cobimetinib
Codeine
Colchicine
Colchicine
Conivaptan
Copanlisib
Crizotinib
CycloSPORINE (Systemic)
CycloSPORINE (Systemic)
CYP3A4 Inducers (Moderate)
CYP3A4 Inducers (Strong)
CYP3A4 Inducers (Strong)
CYP3A4 Inhibitors (Moderate)
CYP3A4 Inhibitors (Strong)
CYP3A4 Substrates (High risk with Inhibitors)
Dabigatran Etexilate
Dabrafenib
Dantrolene
Dapoxetine
Darifenacin
Deferasirox
Deflazacort
Delamanid
DexAMETHasone (Systemic)
Dexmethylphenidate
DiazePAM
Diazoxide
DilTIAZem
Disopyramide
DOCEtaxel
Dofetilide
Domperidone
DOXOrubicin (Conventional)
DOXOrubicin (Conventional)
Dronabinol
Dronedarone
DULoxetine
Ebastine
Edoxaban
Eletriptan
Elexacaftor, Tezacaftor, and Ivacaftor
Eliglustat
Encorafenib
Entrectinib
Eplerenone
Erdafitinib
Erdafitinib
Erlotinib
Erythromycin (Systemic)
Esmolol
Estrogen Derivatives
Eszopiclone
Etoposide
Etoposide Phosphate
Everolimus
Fedratinib
Felodipine
FentaNYL
Fexinidazole
Finerenone
Fingolimod
Flecainide
Flibanserin
Fluticasone (Nasal)
Fluticasone (Oral Inhalation)
Fosaprepitant
Fosphenytoin-Phenytoin
Fusidic Acid (Systemic)
Gilteritinib
Glasdegib
Glecaprevir and Pibrentasvir
Grapefruit Juice
GuanFACINE
Halofantrine
Herbal Products with Blood Pressure Increasing Effects
Herbal Products with Blood Pressure Lowering Effects
HYDROcodone
Hypotension-Associated Agents
Ibrutinib
Ifosfamide
Iloperidone
Infigratinib
Irinotecan Products
Isavuconazonium Sulfate
Isradipine
Ivabradine
Ivacaftor
Ivosidenib
Ixabepilone
Lacosamide
Lapatinib
Larotrectinib
Lefamulin
Lemborexant
Lercanidipine
Levamlodipine
Levodopa-Containing Products
Levomilnacipran
Lidocaine (Systemic)
Lithium
Lomitapide
Lonafarnib
Lormetazepam
Lovastatin
Lumateperone
Lurasidone
Lurbinectedin
Macitentan
Manidipine
Meperidine
MetFORMIN
Methylphenidate
MethylPREDNISolone
Midazolam
Midodrine
Midostaurin
Mirodenafil
Molsidomine
Morphine (Systemic)
Nadolol
Naftopidil
Naldemedine
Nalfurafine
Naloxegol
Neratinib
Neuromuscular-Blocking Agents (Nondepolarizing)
Nicergoline
Nicorandil
NIFEdipine
NiMODipine
Nintedanib
Nisoldipine
Nitrendipine
Nitroprusside
Obinutuzumab
Olaparib
Oliceridine
Olmutinib
OxyCODONE
Ozanimod
PACLitaxel (Conventional)
PACLitaxel (Protein Bound)
Palbociclib
Panobinostat
PAZOPanib
Pemigatinib
Pentoxifylline
Pexidartinib
Pholcodine
Pimavanserin
Pimecrolimus
Pimozide
Piperaquine
PONATinib
Ponesimod
Pralsetinib
Pramipexole
Praziquantel
Prostacyclin Analogues
QUEtiapine
Quinagolide
QuiNIDine
Quinidine (Non-Therapeutic)
QuiNINE
Ranolazine
Red Yeast Rice
Regorafenib
Relugolix
Relugolix, Estradiol, and Norethindrone
Ribociclib
RifAXIMin
Rimegepant
Riociguat
RisperiDONE
Rivaroxaban
Roflumilast
RomiDEPsin
Rupatadine
Ruxolitinib
Salmeterol
Sarilumab
SAXagliptin
Selpercatinib
Selumetinib
Sildenafil
Silodosin
Siltuximab
Simeprevir
Simvastatin
Sincalide
Siponimod
Sirolimus
Sirolimus
Solifenacin
Sonidegib
SUNItinib
Suvorexant
Tacrolimus (Systemic)
Tacrolimus (Topical)
Tadalafil
Talazoparib
Tamsulosin
Tazemetostat
Tegaserod
Temsirolimus
Teniposide
Terfenadine
Terlipressin
Tetrahydrocannabinol
Tetrahydrocannabinol and Cannabidiol
Tezacaftor and Ivacaftor
Theophylline Derivatives
Thiotepa
Ticagrelor
TiZANidine
Tocilizumab
Tofacitinib
Tofacitinib
Tolterodine
Tolvaptan
Topotecan
Toremifene
Trabectedin
TraMADol
TraZODone
Triazolam
Ubrogepant
Udenafil
Ulipristal
Valbenazine
Vardenafil
Vemurafenib
Venetoclax
Venetoclax
Vilazodone
VinBLAStine
VinCRIStine
VinCRIStine (Liposomal)
Vindesine
Vinflunine
Voclosporin
Vorapaxar
Zanubrutinib
Zopiclone