Drug reference

Verapamil hydrochloride

BNF 80 (2020–2021)

Source: BNF 80 (2020–2021)
PDF pages: 197, 198, 199

Review source pages for extracted sections and age labels. BNF dose snippets show only their first line.

Overview

Indications And Dose

Treatment of supraventricular arrhythmias ▶BY MOUTH USING IMMEDIATE-RELEASE MEDICINES ▶Adult: 40–120 mg 3 times a day ▶BY SLOW INTRAVENOUS INJECTION ▶Adult: 5–10 mg, to be given over 2 minutes, preferably with ECG monitoring ▶Elderly: 5–10 mg, to be given over 3 minutes, preferably with ECG monitoring Paroxysmal tachyarrhythmias ▶BY SLOW INTRAVENOUS INJECTION ▶Adult: Initially 5–10 mg, followed by 5 mg after 5–10 minutes if required, to be given over 2 minutes, preferably with ECG monitoring ▶Elderly: Initially 5–10 mg, followed by 5 mg after 5–10 minutes if required, to be given over 3 minutes, preferably with ECG monitoring Angina ▶BY MOUTH USING IMMEDIATE-RELEASE MEDICINES ▶Adult: 80–120 mg 3 times a day Hypertension ▶BY MOUTH USING IMMEDIATE-RELEASE MEDICINES ▶Adult: 240–480 mg daily in 2–3 divided doses Prophylaxis of cluster headache (initiated under specialist supervision) ▶BY MOUTH USING IMMEDIATE-RELEASE MEDICINES ▶Adult: 240–960 mg daily in 3–4 divided doses HALF SECURON ® SR Hypertension (in patients new to verapamil) ▶BY MOUTH ▶Adult: Initially 120 mg daily, increased if necessary up to 480 mg daily, doses above 240 mg daily as 2 divided doses Hypertension ▶BY MOUTH ▶Adult: 240 mg daily, increased if necessary up to 480 mg daily, doses above 240 mg daily as 2 divided doses Angina ▶BY MOUTH ▶Adult: 240 mg twice daily, may sometimes be reduced to once daily Prophylaxis after myocardial infarction where beta- blockers not appropriate ▶BY MOUTH ▶Adult: 360 mg daily in divided doses, started at least 1 week after infarction, given as either 240 mg in the morning and 120 mg in the evening or 120 mg 3 times daily SECURON ® SR Hypertension (in patients new to verapamil) ▶BY MOUTH ▶Adult: Initially 120 mg daily, increased if necessary up to 480 mg daily, doses above 240 mg daily as 2 divided continued → doses Hypertension ▶BY MOUTH ▶Adult: 240 mg daily, increased if necessary up to 480 mg daily, doses above 240 mg daily as 2 divided Cardiovascular system doses Angina ▶BY MOUTH ▶Adult: 240 mg twice daily, may sometimes be reduced to once daily Prophylaxis after myocardial infarction where beta- blockers not appropriate ▶BY MOUTH ▶Adult: 360 mg daily in divided doses, started at least 1 week after infarction, given as either 240 mg in the morning and 120 mg in the evening or 120 mg 3 times daily VERAPRESS ® MR Hypertension ▶BY MOUTH ▶Adult: 240 mg daily, increased if necessary to 240 mg twice daily Angina ▶BY MOUTH ▶Adult: 240 mg twice daily, may sometimes be reduced to once daily VERTAB ® SR 240 Mild to moderate hypertension ▶BY MOUTH ▶Adult: 240 mg daily, increased if necessary to 240 mg twice daily Angina ▶BY MOUTH ▶Adult: 240 mg twice daily, may sometimes be reduced to once daily l UNLICENSED USE ▶With oral use Prophylaxis of cluster headaches is an unlicensed indication.

PDF pages 197, 198

Contra Indications

Acute porphyrias p. 1120. atrial ﬂutter or ﬁbrillation associated with accessory conducting pathways (e.g. Wolff-Parkinson-White-syndrome). bradycardia. cardiogenic shock. heart failure (with reduced ejection fraction). history of signiﬁcantly impaired left ventricular function (even if controlled by therapy). hypotension. second- and third-degree AV block. sick sinus syndrome. sino-atrial block Addison’s disease. hypercalcaemia. hyponatraemia. refractory hypokalaemia. symptomatic hyperuricaemia

PDF page 198

Cautions

Acute phase of myocardial infarction (avoid if bradycardia, hypotension, left ventricular failure). ﬁrst- degree AV block. neuromuscular disorders CAUTIONS, FURTHER INFORMATION ▶Elderly Prescription potentially inappropriate (STOPP criteria) in patients with NYHA Class III or IV heart failure (may worsen heart failure). See also Prescribing in the elderly p. 33. Diabetes. gout. hyperaldosteronism. malnourishment. nephrotic syndrome. systemic lupus erythematosus CAUTIONS, FURTHER INFORMATION ▶Existing conditions Thiazides and related diuretics can exacerbate diabetes, gout, and systemic lupus erythematosus. ▶Potassium loss Hypokalaemia can occur with both thiazide and loop diuretics. The risk of hypokalaemia depends on the duration of action as well as the potency and is thus greater with thiazides than with an equipotent dose of a loop diuretic. Hypokalaemia is dangerous in severe cardiovascular disease and in patients also being treated with cardiac glycosides. Often the use of potassium-sparing diuretics avoids the need to take potassium supplements. Potassium supplements or potassium-sparing diuretics are seldom necessary when thiazides are used in the routine treatment of hypertension. In hepatic failure, hypokalaemia caused by diuretics can precipitate encephalopathy, particularly in alcoholic cirrhosis. ▶Elderly Lower initial doses of diuretics should be used in the elderly because they are particularly susceptible to the side-effects. The dose should then be adjusted according to renal function. Diuretics should not be used continuously on a long-term basis to treat simple gravitational oedema (which will usually respond to increased movement, raising the legs, and support stockings). Prescription potentially inappropriate (STOPP criteria): . with current signiﬁcant hypokalaemia (serum potassium less than 3 mmol/L), hyponatraemia (serum sodium less than 130 mmol/L) or hypercalcaemia (corrected serum calcium greater than 2.65 mmol/L)—hypokalaemia, hyponatraemia and hypercalcaemia can be precipitated by a thiazide diuretic . with a history of gout (gout can be precipitated by a thiazide diuretic) See also Prescribing in the elderly p. 33.

PDF pages 198, 199

Safety

Interactions

→Appendix 1: calcium channel blockers

PDF page 198

Side Effects

GENERAL SIDE-EFFECTS ▶Common or very common Hypotension ▶Frequency not known Atrioventricular block. extrapyramidal symptoms. gynaecomastia. Stevens- Johnson syndrome. vertigo SPECIFIC SIDE-EFFECTS ▶Common or very common ▶With intravenous use Bradycardia ▶Frequency not known ▶With intravenous use Cardiac arrest. hepatic impairment. hyperhidrosis. myocardial contractility decreased. nervousness. seizure ▶With oral use Abdominal discomfort. alopecia. arrhythmias . arthralgia. constipation. erythromelalgia. fatigue. galactorrhoea. heart failure. ileus. muscle weakness. tinnitus. tremor Overdose In overdose, verapamil has a profound cardiac depressant effect causing hypotension and arrhythmias, including complete heart block and asystole. ▶Common or very common Alkalosis hypochloraemic. constipation. diarrhoea. dizziness. dry mouth. electrolyte imbalance. erectile dysfunction. fatigue. headache. hyperglycaemia. hyperuricaemia. nausea. postural hypotension. skin reactions ▶Uncommon Agranulocytosis. aplastic anaemia. leucopenia . pancreatitis. photosensitivity reaction. thrombocytopenia. vomiting ▶Rare or very rare Paraesthesia

PDF pages 198, 199

Pregnancy

May reduce uterine blood ﬂow with fetal hypoxia. Manufacturer advises avoid in ﬁrst trimester unless absolutely necessary. May inhibit labour. Thiazides and related diuretics should not be used to treat gestational hypertension. They may cause neonatal thrombocytopenia, bone marrow suppression, jaundice, electrolyte disturbances, and hypoglycaemia; placental perfusion may also be reduced. Stimulation of labour, uterine inertia, and meconium staining have also been reported.

PDF pages 198, 199

Breast Feeding

Amount too small to be harmful.

PDF page 198

Hepatic Impairment

Dose adjustments ▶With oral use Manufacturer advises dose reduction. In general, manufacturer advises caution in mild to moderate impairment; avoid in severe impairment.

PDF pages 198, 199

Renal Impairment

Thiazides and related diuretics are ineffective if eGFR is less than 30 mL/minute/1.73 m2 and should be avoided. Metolazone remains effective if eGFR is less than 30 mL/minute/1.73 m2 but is associated with a risk of excessive diuresis. Monitoring Electrolytes should be monitored in renal impairment.

PDF page 199

Monitoring Requirements

Electrolytes should be monitored, particularly with high doses and long-term use. eiiii F 176

PDF page 199

Dose and formulations

Medicinal Forms

There can be variation in the licensing of different medicines containing the same drug. Forms available from special-order manufacturers include: oral suspension, oral solution Modified-release tablet CAUTIONARY AND ADVISORY LABELS 25 ▶Half Securon (Mylan) Verapamil hydrochloride 120 mg Half Securon SR 120mg tablets | 28 tablet P £7.71 DT = £7.71 ▶Securon SR (Mylan) Verapamil hydrochloride 240 mg Securon SR 240mg tablets | 28 tablet P £5.55 DT = £5.55 ▶Vera-Til SR (Tillomed Laboratories Ltd, Actavis UK Ltd) Verapamil hydrochloride 120 mg Vera-Til SR 120mg tablets | 28 tablet P £6.98 DT = £7.71 Verapamil hydrochloride 240 mg Vera-Til SR 240mg tablets | 28 tablet P £10.00 DT = £5.55 ▶Verapress MR (Dexcel-Pharma Ltd) Verapamil hydrochloride 240 mg Verapress MR 240mg tablets | 28 tablet P £9.90 DT = £5.55 ▶Vertab SR (Chiesi Ltd) Verapamil hydrochloride 240 mg Vertab SR 240 tablets | 28 tablet P £5.45 DT = £5.55 Tablet ▶Verapamil hydrochloride (Non-proprietary) Verapamil hydrochloride 40 mg Verapamil 40mg tablets | 84 tablet P £2.24 DT = £1.89 Verapamil hydrochloride 80 mg Verapamil 80mg tablets | 84 tablet P £2.63 DT = £2.36 Verapamil hydrochloride 120 mg Verapamil 120mg tablets | 28 tablet P £4.43 DT = £4.02 Verapamil hydrochloride 160 mg Verapamil 160mg tablets | 56 tablet P £33.84 DT = £29.47 Solution for injection ▶Securon (Mylan) Verapamil hydrochloride 2.5 mg per 1 ml Securon IV 5mg/2ml solution for injection ampoules | 5 ampoule P £5.41 Oral solution ▶Verapamil hydrochloride (Non-proprietary) Verapamil hydrochloride 8 mg per 1 ml Verapamil 40mg/5ml oral solution sugar-free | 150 ml P £44.92 DT = £41.00 DIURETICS › THIAZIDES AND RELATED DIURETICS Thiazides and related diuretics f

PDF page 198

Dose text by age group

Adult

40–120 mg 3 times a day

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

5–10 mg, to be given over 2 minutes, preferably

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Elderly

5–10 mg, to be given over 3 minutes,

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

Initially 5–10 mg, followed by 5 mg after

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Elderly

Initially 5–10 mg, followed by 5 mg after

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

80–120 mg 3 times a day

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

240–480 mg daily in 2–3 divided doses

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

240–960 mg daily in 3–4 divided doses

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

Initially 120 mg daily, increased if necessary up

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

240 mg daily, increased if necessary up to

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

240 mg twice daily, may sometimes be reduced

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

360 mg daily in divided doses, started at least

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

Initially 120 mg daily, increased if necessary up

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

240 mg daily, increased if necessary up to

First-line fragment. Read the complete Indications and Dose section above.

PDF page 198

Adult

240 mg twice daily, may sometimes be reduced

First-line fragment. Read the complete Indications and Dose section above.

PDF page 198

Adult

360 mg daily in divided doses, started at least

First-line fragment. Read the complete Indications and Dose section above.

PDF page 198

Adult

240 mg daily, increased if necessary to 240 mg

First-line fragment. Read the complete Indications and Dose section above.

PDF page 198

Adult

240 mg twice daily, may sometimes be reduced

First-line fragment. Read the complete Indications and Dose section above.

PDF page 198

Adult

240 mg daily, increased if necessary to 240 mg

First-line fragment. Read the complete Indications and Dose section above.

PDF page 198

Adult

240 mg twice daily, may sometimes be reduced

First-line fragment. Read the complete Indications and Dose section above.

PDF page 198

Age labels are extracted for navigation. Check the complete source section and current local guidance before clinical use.

Drug reference

Verapamil hydrochloride

BNF 80 (2020–2021)

Source: BNF 80 (2020–2021)
PDF pages: 197, 198, 199

Review source pages for extracted sections and age labels. BNF dose snippets show only their first line.

Overview

Indications And Dose

PDF pages 197, 198

Contra Indications

PDF page 198

Cautions

PDF pages 198, 199

Safety

Interactions

→Appendix 1: calcium channel blockers

PDF page 198

Side Effects

PDF pages 198, 199

Pregnancy

PDF pages 198, 199

Breast Feeding

Amount too small to be harmful.

PDF page 198

Hepatic Impairment

Dose adjustments ▶With oral use Manufacturer advises dose reduction. In general, manufacturer advises caution in mild to moderate impairment; avoid in severe impairment.

PDF pages 198, 199

Renal Impairment

PDF page 199

Monitoring Requirements

Electrolytes should be monitored, particularly with high doses and long-term use. eiiii F 176

PDF page 199

Dose and formulations

Medicinal Forms

PDF page 198

Dose text by age group

Adult

40–120 mg 3 times a day

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

5–10 mg, to be given over 2 minutes, preferably

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Elderly

5–10 mg, to be given over 3 minutes,

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

Initially 5–10 mg, followed by 5 mg after

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Elderly

Initially 5–10 mg, followed by 5 mg after

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

80–120 mg 3 times a day

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

240–480 mg daily in 2–3 divided doses

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

240–960 mg daily in 3–4 divided doses

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

Initially 120 mg daily, increased if necessary up

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

240 mg daily, increased if necessary up to

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

240 mg twice daily, may sometimes be reduced

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

360 mg daily in divided doses, started at least

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

Initially 120 mg daily, increased if necessary up

First-line fragment. Read the complete Indications and Dose section above.

PDF page 197

Adult

240 mg daily, increased if necessary up to

First-line fragment. Read the complete Indications and Dose section above.

PDF page 198

Adult

240 mg twice daily, may sometimes be reduced

First-line fragment. Read the complete Indications and Dose section above.

PDF page 198

Adult

360 mg daily in divided doses, started at least

First-line fragment. Read the complete Indications and Dose section above.

PDF page 198

Adult

240 mg daily, increased if necessary to 240 mg

First-line fragment. Read the complete Indications and Dose section above.

PDF page 198

Adult

240 mg twice daily, may sometimes be reduced

First-line fragment. Read the complete Indications and Dose section above.

PDF page 198

Adult

240 mg daily, increased if necessary to 240 mg

First-line fragment. Read the complete Indications and Dose section above.

PDF page 198

Adult

240 mg twice daily, may sometimes be reduced

First-line fragment. Read the complete Indications and Dose section above.

PDF page 198

Age labels are extracted for navigation. Check the complete source section and current local guidance before clinical use.