The Food and Drug Administration (FDA) approved indications for verapamil are as follows:
The non-FDA-approved indications for verapamil are as follows:
Acute Coronary Syndrome (ACS)
Given as initial treatment in patients with: (1) Non-ST elevation acute coronary syndrome(NSTE-ACS, (2) continuing or frequently recurring ischemia and are unable to use beta-blockers (e.g., contraindication, suffered from unacceptable adverse effects, beta-blockers were insufficient for treatment) in the absence of:
Furthermore, long-acting calcium channel blockers and nitrates are recommended in patients with coronary artery spasm (short-acting calcium channel antagonists should be avoided).
Used as a first-line prophylactic at a minimum dosage of 240 mg per day per recommendation to reduce headache severity and decrease the frequency of episodes during a cluster period.
Hypertrophic Cardiomyopathy (HCM):
Recommended for the treatment of symptoms (e.g., angina or dyspnea) in patients with obstructive or non-obstructive HCM who are unable to take beta-blockers (e.g., side effects/contraindications to beta-blockers, unresponsive to beta-blockers).
Idiopathic Ventricular Tachycardia (IVT):
There are reports that the chronic use of oral verapamil for verapamil-sensitive idiopathy LVT can control IVT in many patients in both adults and children.
Verapamil is a non-dihydropyridine calcium channel blocker. Calcium channel blockers inhibit the entry of calcium ions into the slow L-type calcium channels in the myocardium and vascular smooth muscle during depolarization. This inhibition will produce relaxation of coronary vascular smooth muscle as well as coronary vasodilation, which is helpful in patients with hypertension. Verapamil also increases myocardial oxygen delivery, which helps patients with vasospastic angina. Verapamil correlates with negative chronotropic effects and a decrease in sympathetic nervous system activity.
Verapamil can be administered either orally (sustained release or immediate release) or intravenously. It is possible to open sustained-release verapamil capsules, and the contents sprinkled on one tablespoon of applesauce. Patients should receive instructions to swallow immediately with a full glass of cool water. For sustained verapamil products, take with food and swallow whole (should not be chewed or crushed). When given intravenously, verapamil administration must be over at least a two-minute timeframe.
Ongoing Management of SVT:
ACC/AHA/HRS SVT guidelines
Although verapamil is present in breast milk, the relative infant dose of verapamil is less than or equal to 1% of the weight-adjusted maternal dose which is below the required RID limit of less than 10 %. Therefore, breastfeeding is acceptable for verapamil, though some manufacturers are against it.
For patients who are on verapamil, the clinician should monitor their blood pressure, heart rate, and liver function tests.
Goals of Therapy:
Like all calcium channel blockers, an overdose of verapamil can lead to negative inotropic and chronotropic effects, dilation of arterial vasculature, and hypotension. Additionally, verapamil’s blockade of slow calcium channels in pancreatic beta cells can lead to inhibition in insulin release, thereby causing hyperglycemia. If a patient experiences bradycardia with hypotension/metabolic acidosis and hyperglycemia is indicative of verapamil toxicity. The most serious complications from a verapamil overdose are bradycardia and hypotension, as both can lead to death if the patient is left untreated.
If a patient presents with verapamil toxicity within 1 hour, two decontamination procedures exist; gastric lavage and single-dose activated charcoal. If a patient presents with verapamil toxicity after 1 hour of ingestion has elapsed, whole bowel irrigation using polyethylene glycol electrolyte solution is a viable decontamination procedure. According to experimental and clinical studies, ipecac and cathartics have not proven to be beneficial decontamination procedures.
Treatment of Calcium Channel Blocker Overdose
Patients with symptoms should undergo treatment with the prioritization of first-line therapy. Determination of which treatment is first-line depends upon the desired effect to include:
Patients refractory to first-line therapies:
Patients with refractory shock/precardiac-arrest:
Administration of calcium chloride or calcium gluconate in symptomatic patients is another therapeutic alternative. Calcium chloride is used in nonacidotic patients due to its delivering three times the amount of calcium than in calcium gluconate. In contrast, calcium gluconate is used in acidotic patients because calcium chloride could worsen the acidosis. Both calcium formulations must have IV administration.
Healthcare professionals (pharmacists, nurses, and doctors) who prescribe and distribute this medication should be aware of the side effects, sound-alike look-alike issues between the verapamil brand names and monitor, heart rate, and blood pressure. Pharmacists should educate patients on the side effects and what to do if they feel these side effects. Further, they should keep track of other medications that the patient is taking to avoid drug-drug interactions. Pharmacists should also educate doctors and nurses on the differences between oral and IV dosing and to use with caution when converting from one route to another. When a doctor decides to switch from oral formulation to intravenous formulation, the total daily dose of verapamil will remain the same unless the strength of the formulation does not allow for direct mg for mg conversion. There fore, nurses and clinicians should engage the pharmacist when prescribing or counseling on the dosing and administration of the various formulations, and nursing should understand this information for their counseling. This type of interprofessional communication will lead to improved outcomes using verapamil. [Level 5]
|||Amsterdam EA,Wenger NK,Brindis RG,Casey DE Jr,Ganiats TG,Holmes DR Jr,Jaffe AS,Jneid H,Kelly RF,Kontos MC,Levine GN,Liebson PR,Mukherjee D,Peterson ED,Sabatine MS,Smalling RW,Zieman SJ, 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology. 2014 Dec 23; [PubMed PMID: 25260718]|
|||Weaver-Agostoni J, Cluster headache. American family physician. 2013 Jul 15; [PubMed PMID: 23939643]|
|||Gersh BJ,Maron BJ,Bonow RO,Dearani JA,Fifer MA,Link MS,Naidu SS,Nishimura RA,Ommen SR,Rakowski H,Seidman CE,Towbin JA,Udelson JE,Yancy CW, 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. The Journal of thoracic and cardiovascular surgery. 2011 Dec; [PubMed PMID: 22093723]|
|||Al-Khatib SM,Stevenson WG,Ackerman MJ,Bryant WJ,Callans DJ,Curtis AB,Deal BJ,Dickfeld T,Field ME,Fonarow GC,Gillis AM,Granger CB,Hammill SC,Hlatky MA,Joglar JA,Kay GN,Matlock DD,Myerburg RJ,Page RL, 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: Executive summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart rhythm. 2018 Oct; [PubMed PMID: 29097320]|
|||Basile J, The role of existing and newer calcium channel blockers in the treatment of hypertension. Journal of clinical hypertension (Greenwich, Conn.). 2004 Nov; [PubMed PMID: 15538095]|
|||Flynn JT,Pasko DA, Calcium channel blockers: pharmacology and place in therapy of pediatric hypertension. Pediatric nephrology (Berlin, Germany). 2000 Dec; [PubMed PMID: 11149130]|
|||Whelton PK,Carey RM,Aronow WS,Casey DE Jr,Collins KJ,Dennison Himmelfarb C,DePalma SM,Gidding S,Jamerson KA,Jones DW,MacLaughlin EJ,Muntner P,Ovbiagele B,Smith SC Jr,Spencer CC,Stafford RS,Taler SJ,Thomas RJ,Williams KA Sr,Williamson JD,Wright JT Jr, 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension (Dallas, Tex. : 1979). 2018 Jun; [PubMed PMID: 29133356]|
|||Aronow WS,Fleg JL,Pepine CJ,Artinian NT,Bakris G,Brown AS,Ferdinand KC,Forciea MA,Frishman WH,Jaigobin C,Kostis JB,Mancia G,Oparil S,Ortiz E,Reisin E,Rich MW,Schocken DD,Weber MA,Wesley DJ,Harrington RA, ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation. 2011 May 31; [PubMed PMID: 21518977]|
|||Gibbons RJ,Abrams J,Chatterjee K,Daley J,Deedwania PC,Douglas JS,Ferguson TB Jr,Fihn SD,Fraker TD Jr,Gardin JM,O'Rourke RA,Pasternak RC,Williams SV, ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina). Journal of the American College of Cardiology. 2003 Jan 1; [PubMed PMID: 12570960]|
|||January CT,Wann LS,Alpert JS,Calkins H,Cigarroa JE,Cleveland JC Jr,Conti JB,Ellinor PT,Ezekowitz MD,Field ME,Murray KT,Sacco RL,Stevenson WG,Tchou PJ,Tracy CM,Yancy CW, 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014 Dec 2; [PubMed PMID: 24682347]|
|||Phillips BG,Gandhi AJ,Sanoski CA,Just VL,Bauman JL, Comparison of intravenous diltiazem and verapamil for the acute treatment of atrial fibrillation and atrial flutter. Pharmacotherapy. 1997 Nov-Dec; [PubMed PMID: 9399606]|
|||Al-Khatib SM,Stevenson WG,Ackerman MJ,Bryant WJ,Callans DJ,Curtis AB,Deal BJ,Dickfeld T,Field ME,Fonarow GC,Gillis AM,Granger CB,Hammill SC,Hlatky MA,Joglar JA,Kay GN,Matlock DD,Myerburg RJ,Page RL, 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. Circulation. 2018 Sep 25; [PubMed PMID: 29084731]|
|||Gill JS,Blaszyk K,Ward DE,Camm AJ, Verapamil for the suppression of idiopathic ventricular tachycardia of left bundle branch block-like morphology. American heart journal. 1993 Nov; [PubMed PMID: 8237755]|
|||Gill JS,Mehta D,Ward DE,Camm AJ, Efficacy of flecainide, sotalol, and verapamil in the treatment of right ventricular tachycardia in patients without overt cardiac abnormality. British heart journal. 1992 Oct; [PubMed PMID: 1449923]|
|||Gill JS,Ward DE,Camm AJ, Comparison of verapamil and diltiazem in the suppression of idiopathic ventricular tachycardia. Pacing and clinical electrophysiology : PACE. 1992 Nov; [PubMed PMID: 1279611]|
|||May A,Leone M,Afra J,Linde M,Sándor PS,Evers S,Goadsby PJ, EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. European journal of neurology. 2006 Oct; [PubMed PMID: 16987158]|
|||Robbins MS,Starling AJ,Pringsheim TM,Becker WJ,Schwedt TJ, Treatment of Cluster Headache: The American Headache Society Evidence-Based Guidelines. Headache. 2016 Jul; [PubMed PMID: 27432623]|
|||Page RL,Joglar JA,Caldwell MA,Calkins H,Conti JB,Deal BJ,Estes NAM 3rd,Field ME,Goldberger ZD,Hammill SC,Indik JH,Lindsay BD,Olshansky B,Russo AM,Shen WK,Tracy CM,Al-Khatib SM, 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Journal of the American College of Cardiology. 2016 Apr 5; [PubMed PMID: 26409259]|
|||Neumar RW,Otto CW,Link MS,Kronick SL,Shuster M,Callaway CW,Kudenchuk PJ,Ornato JP,McNally B,Silvers SM,Passman RS,White RD,Hess EP,Tang W,Davis D,Sinz E,Morrison LJ, Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2; [PubMed PMID: 20956224]|
|||Yancy CW,Jessup M,Bozkurt B,Butler J,Casey DE Jr,Drazner MH,Fonarow GC,Geraci SA,Horwich T,Januzzi JL,Johnson MR,Kasper EK,Levy WC,Masoudi FA,McBride PE,McMurray JJ,Mitchell JE,Peterson PN,Riegel B,Sam F,Stevenson LW,Tang WH,Tsai EJ,Wilkoff BL, 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013 Oct 15; [PubMed PMID: 23741058]|
|||Gersh BJ,Maron BJ,Bonow RO,Dearani JA,Fifer MA,Link MS,Naidu SS,Nishimura RA,Ommen SR,Rakowski H,Seidman CE,Towbin JA,Udelson JE,Yancy CW, 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011 Dec 13; [PubMed PMID: 22068434]|
|||Nishimura RA,Holmes DR Jr, Clinical practice. Hypertrophic obstructive cardiomyopathy. The New England journal of medicine. 2004 Mar 25; [PubMed PMID: 15044643]|
|||Tan HL,Lie KI, Treatment of tachyarrhythmias during pregnancy and lactation. European heart journal. 2001 Mar; [PubMed PMID: 11237540]|
|||Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstetrics and gynecology. 2013 Nov; [PubMed PMID: 24150027]|
|||Anderson P,Bondesson U,Mattiasson I,Johansson BW, Verapamil and norverapamil in plasma and breast milk during breast feeding. European journal of clinical pharmacology. 1987; [PubMed PMID: 3830249]|
|||Miller MR,Withers R,Bhamra R,Holt DW, Verapamil and breast-feeding. European journal of clinical pharmacology. 1986; [PubMed PMID: 3709626]|
|||Ito S, Drug therapy for breast-feeding women. The New England journal of medicine. 2000 Jul 13; [PubMed PMID: 10891521]|
|||Andersen HJ, Excretion of verapamil in human milk. European journal of clinical pharmacology. 1983; [PubMed PMID: 6628513]|
|||Inoue H,Unno N,Ou MC,Iwama Y,Sugimoto T, Level of verapamil in human milk. European journal of clinical pharmacology. 1984; [PubMed PMID: 6468488]|
|||Aleyadeh W,Hutt-Centeno E,Ahmed HM,Shah NP, Hypertension guidelines: Treat patients, not numbers. Cleveland Clinic journal of medicine. 2019 Jan [PubMed PMID: 30624184]|
|||Benson BE,Hoppu K,Troutman WG,Bedry R,Erdman A,Höjer J,Mégarbane B,Thanacoody R,Caravati EM, Position paper update: gastric lavage for gastrointestinal decontamination. Clinical toxicology (Philadelphia, Pa.). 2013 Mar; [PubMed PMID: 23418938]|
|||Chyka PA,Seger D,Krenzelok EP,Vale JA, Position paper: Single-dose activated charcoal. Clinical toxicology (Philadelphia, Pa.). 2005; [PubMed PMID: 15822758]|
|||Thanacoody R,Caravati EM,Troutman B,Höjer J,Benson B,Hoppu K,Erdman A,Bedry R,Mégarbane B, Position paper update: whole bowel irrigation for gastrointestinal decontamination of overdose patients. Clinical toxicology (Philadelphia, Pa.). 2015 Jan; [PubMed PMID: 25511637]|
|||Poison treatment in the home. American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Pediatrics. 2003 Nov; [PubMed PMID: 14595067]|
|||Höjer J,Troutman WG,Hoppu K,Erdman A,Benson BE,Mégarbane B,Thanacoody R,Bedry R,Caravati EM, Position paper update: ipecac syrup for gastrointestinal decontamination. Clinical toxicology (Philadelphia, Pa.). 2013 Mar; [PubMed PMID: 23406298]|
|||St-Onge M,Anseeuw K,Cantrell FL,Gilchrist IC,Hantson P,Bailey B,Lavergne V,Gosselin S,Kerns W 2nd,Laliberté M,Lavonas EJ,Juurlink DN,Muscedere J,Yang CC,Sinuff T,Rieder M,Mégarbane B, Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults. Critical care medicine. 2017 Mar; [PubMed PMID: 27749343]|