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):
The chronic use of oral verapamil for verapamil-sensitive idiopathy LVT has been reported to 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 1 tablespoon of applesauce. Patients should be instructed 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.
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