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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
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