Drugs List

Therapeutic Indications

Uses

Atrial flutter/fibrillation: Reduction of ventricular rate
Supra-ventricular tachycardia

Administration

For slow intravenous injection only.

Contraindications

Systolic blood pressure < 90mmHg
Bradycardia - if treating myocardial infarction
Bradycardia with pulse rate at rest < 50 beats per minute
Cardiogenic shock
Decompensated cardiac failure
History of cardiac failure
Hypotension - if treating myocardial infarction
Left ventricular dysfunction - if treating myocardial infarction
Lown-Ganong-Levine syndrome
Non paced second/third degree AV block
Non-paced sinus node dysfunction
Porphyria
Severe left ventricular failure
Sinoatrial exit block
Wolff-Parkinson-White syndrome

Precautions and Warnings

Elderly
Bradycardia
Breastfeeding
Cardiac failure
Duchenne muscular dystrophy
First degree atrioventricular block
Labour
Myasthenia gravis
Myasthenic Eaton-Lambert syndrome
Pregnancy
Severe hepatic impairment
Severe renal impairment

Control cardiac failure before starting treatment
Not removed via dialysis
Children under 18: Treatment to be initiated/supervised by a specialist
Monitor blood pressure and ECG continuously throughout treatment
Monitor patients for signs and symptoms of cardiac failure
May precipitate or aggravate cardiac failure even in controlled cases
Pregnancy: This medication may inhibit labour
Advise patient not to take aspirin unless advised by clinician
Advise patient not to take simvastatin unless advised by clinician
Advise patient not to take St John's wort concurrently
Advise patient grapefruit products may increase plasma level

Verapamil injection should not be given to patients recently treated with beta blockers because of the risk of hypotension and asystole. The suggestion that when verapamil injection has been given first, an interval of 30 minutes before giving a beta-blocker is sufficient has not been confirmed.

Duration of action may be prolonged in patients with significant renal or hepatic impairment.

Pregnancy and Lactation

Pregnancy

Use verapamil hydrochloride with caution during pregnancy.

Verapamil should not be given during the first trimester of pregnancy unless it is considered essential. Verapamil crosses the placenta and can be detected in umbilical vein blood at delivery. Verapamil may inhibit labour and reduce uterine blood flow with foetal hypoxia. In some cases it has been associated with maternal hyperprolactinaemia and galactorrhoea.

Briggs (2015) suggests that the use of verapamil hydrochloride appears to be low risk during any stage of pregnancy.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use verapamil hydrochloride with caution during breastfeeding.

Verapamil is excreted in breast milk in small amounts and is unlikely to be harmful. Schaefer (2015) notes that verapamil hydrochloride is one of the calcium antagonists of choice during breastfeeding. Briggs (2015) also concludes that verapamil hydrochloride is probably compatible with breastfeeding.

LactMed comments that low levels of verapamil are found in breast milk but verapamil would not be expected to cause any adverse effects in nursing infants, especially if the infant is older than 2 months.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Abdominal pain
Allergic reaction
Angioedema
Ankle oedema
Arthralgia
Asystole
Bradycardia
Bronchospasm
Cardiac conduction disturbances
Cardiac failure
Constipation
Dizziness
Erythema
Erythromelalgia
Extrapyramidal effects
Fatigue
Flushing
Gingival hyperplasia
Gynaecomastia
Headache
Hepatic impairment
Hyperhidrosis
Hypersensitivity reactions
Hypotension
Increased prolactin
Increases in hepatic enzymes (reversible)
Myalgia
Myocardial depression
Nausea
Nervousness
Paraesthesia
Pruritus
Second and third degree AV block
Seizures
Somnolence
Stevens-Johnson syndrome
Tachycardia
Urticaria
Vertigo
Vomiting
Worsening heart failure

Presentation

Solution for injection containing verapamil hydrochloride

Drugs List

Therapeutic Indications

Uses

Atrial flutter/fibrillation: Reduction of ventricular rate
Supra-ventricular tachycardia

Dosage

Adults

Elderly

Children

Administration

For slow intravenous injection only.

Contraindications

Systolic blood pressure < 90mmHg
Bradycardia - if treating myocardial infarction
Bradycardia with pulse rate at rest < 50 beats per minute
Cardiogenic shock
Decompensated cardiac failure
History of cardiac failure
Hypotension - if treating myocardial infarction
Left ventricular dysfunction - if treating myocardial infarction
Lown-Ganong-Levine syndrome
Non paced second/third degree AV block
Non-paced sinus node dysfunction
Porphyria
Severe left ventricular failure
Sinoatrial exit block
Wolff-Parkinson-White syndrome

Precautions and Warnings

Elderly
Bradycardia
Breastfeeding
Cardiac failure
Duchenne muscular dystrophy
First degree atrioventricular block
Labour
Myasthenia gravis
Myasthenic Eaton-Lambert syndrome
Pregnancy
Severe hepatic impairment
Severe renal impairment

Control cardiac failure before starting treatment
Not removed via dialysis
Children under 18: Treatment to be initiated/supervised by a specialist
Monitor blood pressure and ECG continuously throughout treatment
Monitor patients for signs and symptoms of cardiac failure
May precipitate or aggravate cardiac failure even in controlled cases
Pregnancy: This medication may inhibit labour
Advise patient not to take aspirin unless advised by clinician
Advise patient not to take simvastatin unless advised by clinician
Advise patient not to take St John's wort concurrently
Advise patient grapefruit products may increase plasma level

Verapamil injection should not be given to patients recently treated with beta blockers because of the risk of hypotension and asystole. The suggestion that when verapamil injection has been given first, an interval of 30 minutes before giving a beta-blocker is sufficient has not been confirmed.

Duration of action may be prolonged in patients with significant renal or hepatic impairment.

Pregnancy and Lactation

Pregnancy

Use verapamil hydrochloride with caution during pregnancy.

Verapamil should not be given during the first trimester of pregnancy unless it is considered essential. Verapamil crosses the placenta and can be detected in umbilical vein blood at delivery. Verapamil may inhibit labour and reduce uterine blood flow with foetal hypoxia. In some cases it has been associated with maternal hyperprolactinaemia and galactorrhoea.

Briggs (2015) suggests that the use of verapamil hydrochloride appears to be low risk during any stage of pregnancy.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use verapamil hydrochloride with caution during breastfeeding.

Verapamil is excreted in breast milk in small amounts and is unlikely to be harmful. Schaefer (2015) notes that verapamil hydrochloride is one of the calcium antagonists of choice during breastfeeding. Briggs (2015) also concludes that verapamil hydrochloride is probably compatible with breastfeeding.

LactMed comments that low levels of verapamil are found in breast milk but verapamil would not be expected to cause any adverse effects in nursing infants, especially if the infant is older than 2 months.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Abdominal pain
Allergic reaction
Angioedema
Ankle oedema
Arthralgia
Asystole
Bradycardia
Bronchospasm
Cardiac conduction disturbances
Cardiac failure
Constipation
Dizziness
Erythema
Erythromelalgia
Extrapyramidal effects
Fatigue
Flushing
Gingival hyperplasia
Gynaecomastia
Headache
Hepatic impairment
Hyperhidrosis
Hypersensitivity reactions
Hypotension
Increased prolactin
Increases in hepatic enzymes (reversible)
Myalgia
Myocardial depression
Nausea
Nervousness
Paraesthesia
Pruritus
Second and third degree AV block
Seizures
Somnolence
Stevens-Johnson syndrome
Tachycardia
Urticaria
Vertigo
Vomiting
Worsening heart failure

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Further Information

Last Full Review Date: February 2017

Reference Sources

Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 3rd edition (2015) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 10th edition (2015) ed. Briggs, G., Freeman, R. Wolters Kluwer Health, Philadelphia.

Summary of Product Characteristics: Securon I.V. Mylan Products Limited. Revised November 2016.

NICE Evidence Services Available at: www.nice.org.uk Last accessed: 24 August 2017

The Norwegian Porphyria Centre (NAPOS).
Available at: https://www.drugs-porphyria.org
Last revised: 16 April 2010
Last accessed: 16 January 2017

US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Verapamil. Last revised: 10 March 2015
Last accessed: 16 January 2016