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verapamil hydrochloride

(ver ap' a mill)


Calan, Calan SR, Covera-HS, Isoptin, Isoptin SR, Verelan, Verelan PM

Pregnancy Category C

Drug classes
Calcium channel-blocker
Antianginal
Antiarrhythmic
Antihypertensive

Therapeutic actions
Inhibits the movement of calcium ions across the membranes of cardiac and arterial
muscle cells; calcium is involved in the generation of the action potential in specialized
automatic and conducting cells in the heart, in arterial smooth muscle, and in excitation-
contraction coupling in cardiac muscle cells; inhibition of transmembrane calcium flow
results in the depression of impulse formation in specialized cardiac pacemaker cells,
slowing of the velocity of conduction of the cardiac impulse, the depression of
myocardial contractility, and the dilation of coronary arteries and arterioles and peripheral
arterioles; these effects lead to decreased cardiac work, decreased cardiac energy
consumption, and in patients with vasospastic (Prinzmetal's) angina, increased delivery of
oxygen to myocardial cells.

Indications
• Angina pectoris due to coronary artery spasm (Prinzmetal's variant angina)
• Effort-associated angina
• Chronic stable angina in patients who cannot tolerate or do not respond to beta-
adrenergic blockers or nitrates
• Unstable, crescendo, preinfarction angina
• Sustained-release oral only: Essential hypertension
• Parenteral: Treatment of supraventricular tachyarrhythmias
• Parenteral: Temporary control of rapid ventricular rate in atrial flutter or atrial
fibrillation
• Unlabeled oral uses: Paroxysmal supraventricular tachycardia, migraine
headache, nocturnal leg cramps, hypertrophic cardiomyopathy

Contraindications and cautions


• Contraindicated with allergy to verapamil; sick sinus syndrome, except with
ventricular pacemaker; heart block (second- or third-degree); hypotension;
pregnancy; lactation.
• Use cautiously with idiopathic hypertrophic subaortic stenosis, cardiogenic shock,
severe CHF, impaired renal or hepatic function, and in patients with atrial flutter
or atrial fibrillation and an accessory to bypass tract.

Available forms
Tablets—40, 80, 120 mg; SR tablets—120, 180, 240 mg; ER tablets—120, 180, 240 mg;
SR capsules—120, 180, 240, 360 mg; injection—2.5 mg/mL; ER capsules—100, 120,
180, 200, 240, 300, 360 mg

Dosages
ADULTS
Oral
Initial dose, 80–120 mg tid; increase dose every 1–2 days to achieve optimum therapeutic
effects. Usual maintenance dose, 320–480 mg/day.
• Hypertension: 120–240 mg PO daily, sustained-release form in morning. 80 mg
PO tid; ER capsules—100–300 mg PO hs.
Parenteral
IV use only. Initial dose, 5–10 mg over 2 min; may repeat dose of 10 mg 30 min after
first dose if initial response is inadequate.
PEDIATRIC PATIENTS
IV
< 1 yr: Initial dose, 0.1–0.2 mg/kg over 2 min.
1–15 yr: Initial dose, 0.1–0.3 mg/kg over 2 min. Do not exceed 5 mg. Repeat above dose
30 min after initial dose if response is not adequate. Repeat dose should not exceed
10 mg.
GERIATRIC PATIENTS OR PATIENTS WITH RENAL IMPAIRMENT
Reduce dosage, and monitor patient response carefully. Give IV doses over 3 min to
reduce risk of serious side effects. Administer IV doses very slowly, over 2 min.

Pharmacokinetics
Route Onset Peak Duration
Oral 30 min 1–2.2 hr 3–7 hr
IV 1–5 min 3–5 min 2 hr

Metabolism: Hepatic; T1/2: 3–7 hr


Distribution: Crosses placenta; enters breast milk
Excretion: Urine

IV facts
Preparation: No further preparation required.
Infusion: Infuse very slowly over 2–3 min.
Y-site incompatibilities: Do not give with albumin, ampicillin, nafcillin, oxacillin,
sodium bicarbonate, amphotericin B, hydralazine, aminophylline.

Adverse effects
• CNS: Dizziness, vertigo, emotional depression, sleepiness, headache
• CV: Peripheral edema, hypotension, arrhythmias, bradycardia; AV heart block
• GI: Nausea, constipation
• Other: Muscle fatigue, diaphoresis, rash

Interactions
Drug-drug
• Increased cardiac depression with beta-adrenergic blocking agents
• Additive effects of verapamil and digoxin to slow AV conduction
• Increased serum levels of digoxin, carbamazepine, prazosin, quinidine
• Increased respiratory depression with atracurium, gallamine, pancuronium,
tubocurarine, vecuronium
• Risk of serious cardiac effects with IV beta-adrenergic blocking agents; do not
give these drugs within 48 hr before or 24 hr after IV verapamil
• Decreased effects with calcium, rifampin
Drug-food
• Decreased metabolism and risk of toxic effects if combined with grapefruit juice;
avoid this combination

Nursing considerations
Assessment
• History: Allergy to verapamil; sick sinus syndrome; heart block; IHSS;
cardiogenic shock, severe CHF; hypotension; impaired hepatic or renal function;
pregnancy, lactation
• Physical: Skin color, edema; orientation, reflexes; P, BP, baseline ECG,
peripheral perfusion, auscultation; R, adventitious sounds; liver evaluation,
normal output; liver function tests, renal function tests, urinalysis

Interventions
• Monitor patient carefully (BP, cardiac rhythm, and output) while drug is being
titrated to therapeutic dose. Dosage may be increased more rapidly in hospitalized
patients under close supervision.
• Ensure that patient swallows SR tablets whole: do not cut, crush, or chew them.
• Monitor BP very carefully with concurrent doses of antihypertensives.
• Monitor cardiac rhythm regularly during stabilization of dosage and periodically
during long-term therapy.
• Administer sustained-release form in the morning with food to decrease GI upset.
• Protect IV solution from light.
• Monitor patients with renal or hepatic impairment carefully for possible drug
accumulation and adverse reactions.

Teaching points
• Take sustained-release form in the morning with food; swallow whole, do not cut,
crush, or chew it. Do not drink grapefruit juice while using this drug.
• These side effects may occur: Nausea, vomiting (eat frequent small meals);
headache (adjust lighting, noise, and temperature; request medication); dizziness,
sleepiness (avoid driving or operating dangerous equipment); emotional
depression (reversible); constipation (request aid).
• Report irregular heart beat, shortness of breath, swelling of the hands or feet,
pronounced dizziness, nausea, constipation.
Adverse effects in Italic are most common; those in Bold are life-threatening.