Verapamil 180mg ER Capsules
It is used to treat high blood pressure.It may be given to you for other reasons. Talk with the doctor.
Drug Class
Antihypertensive, Antiarrhythmic, Antianginal
Pharmacologic Class
Non-dihydropyridine Calcium Channel Blocker
Pregnancy Category
Category C
FDA Approved
Jan 1970
DEA Schedule
Not Controlled
Overview
What is this medicine?
Verapamil is a medication that helps relax blood vessels and slow down your heart rate. This can lower your blood pressure, reduce chest pain (angina), and help control certain irregular heart rhythms. It's a type of calcium channel blocker.
How to Use This Medicine
Taking Your Medication Correctly
To get the most benefit from your medication, it's essential to take it as directed by your doctor. Carefully read all the information provided with your prescription, and follow the instructions closely.
Some medications are best taken at bedtime, while others can be taken at any time. If you're unsure about the best time to take your medication, consult with your pharmacist.
When taking your medication, swallow the tablet or capsule whole. Do not chew or crush it, as this can affect how the medication works. If you have difficulty swallowing the medication whole, you can sprinkle the contents onto a small amount of applesauce. However, be sure to swallow the mixture immediately without chewing, and avoid mixing it with hot applesauce.
Continue taking your medication as prescribed by your doctor or healthcare provider, even if you start to feel better. This will help ensure that you receive the full benefits of the medication.
Storing and Disposing of Your Medication
To maintain the effectiveness and safety of your medication, store it at room temperature, protected from light and moisture. Avoid storing it in a bathroom, and keep it out of reach of children and pets.
When your medication is no longer needed or has expired, dispose of it properly. Do not flush it down the toilet or pour it down the drain unless instructed to do so by your pharmacist. Instead, check with your pharmacist for guidance on the best way to dispose of your medication. You may also want to explore local drug take-back programs in your area.
What to Do If You Miss a Dose
If you miss a dose of your medication, take it as soon as you remember. However, if it's close to the time for your next scheduled dose, skip the missed dose and continue with your regular dosing schedule. Do not take two doses at the same time or take extra doses to make up for the missed one.
To get the most benefit from your medication, it's essential to take it as directed by your doctor. Carefully read all the information provided with your prescription, and follow the instructions closely.
Some medications are best taken at bedtime, while others can be taken at any time. If you're unsure about the best time to take your medication, consult with your pharmacist.
When taking your medication, swallow the tablet or capsule whole. Do not chew or crush it, as this can affect how the medication works. If you have difficulty swallowing the medication whole, you can sprinkle the contents onto a small amount of applesauce. However, be sure to swallow the mixture immediately without chewing, and avoid mixing it with hot applesauce.
Continue taking your medication as prescribed by your doctor or healthcare provider, even if you start to feel better. This will help ensure that you receive the full benefits of the medication.
Storing and Disposing of Your Medication
To maintain the effectiveness and safety of your medication, store it at room temperature, protected from light and moisture. Avoid storing it in a bathroom, and keep it out of reach of children and pets.
When your medication is no longer needed or has expired, dispose of it properly. Do not flush it down the toilet or pour it down the drain unless instructed to do so by your pharmacist. Instead, check with your pharmacist for guidance on the best way to dispose of your medication. You may also want to explore local drug take-back programs in your area.
What to Do If You Miss a Dose
If you miss a dose of your medication, take it as soon as you remember. However, if it's close to the time for your next scheduled dose, skip the missed dose and continue with your regular dosing schedule. Do not take two doses at the same time or take extra doses to make up for the missed one.
Lifestyle & Tips
- Take exactly as prescribed, usually once daily. Do not crush, chew, or break extended-release capsules.
- Take with food to reduce stomach upset, if recommended by your doctor.
- Avoid grapefruit and grapefruit juice, as they can increase the amount of verapamil in your body and lead to side effects.
- Limit alcohol consumption, as it can worsen dizziness and lower blood pressure.
- Maintain a healthy diet, low in sodium, and engage in regular physical activity as advised by your doctor.
- Report any new or worsening symptoms to your healthcare provider.
Available Forms & Alternatives
Available Strengths:
- Verapamil 120mg ER Capsules
- Verapamil 240mg ER Capsules
- Verapamil 180mg ER Capsules
- Verapamil 40mg Tablets
- Verapamil 360mg SR Capsules
- Verapamil 2.5mg/ml Inj, 4ml
- Verapamil 80mg Tablets
- Verapamil 120mg Tablets
- Verapamil ER 100mg Caps PM (24 Hr)
- Verapamil ER 200mg Capsules (24 Hr)
- Verapamil ER 300mg Capsules (24 Hr)
- Verapamil ER 240mg Tablets
- Verapamil 2.5mg/ml Inj, 2ml
- Verapamil ER 180mg Tablets
- Verapamil ER 120mg Tablets
- Verapamil 80mg Tablets
- Verapamil 2.5mg/ml Inj, 4ml
- Verapamil 2.5mg/ml Inj, 5x2ml Vial
- Verapamil 40mg Tablets
- Verapamil 120mg Tablets
- Verapamil ER 300mg Capsules
Dosing & Administration
Adult Dosing
Standard Dose:
180 mg orally once daily
Dose Range:
120 - 480 mg
Condition-Specific Dosing:
hypertension:
Initial: 180 mg ER orally once daily. May titrate up to 240 mg, 360 mg, or 480 mg once daily. Max: 480 mg/day.
angina:
Initial: 180 mg ER orally once daily. May titrate up to 240 mg, 360 mg, or 480 mg once daily. Max: 480 mg/day.
supraventricularTachyarrhythmias:
Not typically used for acute treatment of SVT with ER formulation; IV formulation is preferred. For chronic management, dosing similar to hypertension/angina.
Pediatric Dosing
Neonatal:
Not established
Infant:
Not established
Child:
Not established for ER capsules. Immediate-release formulations or IV may be used for specific indications (e.g., SVT) under specialist supervision.
Adolescent:
Not established for ER capsules. Immediate-release formulations or IV may be used for specific indications (e.g., SVT) under specialist supervision.
Dose Adjustments
Renal Impairment:
Mild:
No specific adjustment recommended, monitor for adverse effects.
Moderate:
No specific adjustment recommended, monitor for adverse effects.
Severe:
Use with caution, monitor for adverse effects. Verapamil is not dialyzable.
Dialysis:
Not dialyzable. Use with caution, monitor for adverse effects.
Hepatic Impairment:
Mild:
Consider lower initial doses (e.g., 120 mg ER once daily) and titrate cautiously.
Moderate:
Reduce dose by 70-80% (e.g., 60-90 mg ER once daily) and titrate cautiously. Monitor closely for adverse effects.
Severe:
Contraindicated or use with extreme caution and significant dose reduction (e.g., 60 mg ER once daily) due to extensive hepatic metabolism and prolonged half-life. Monitor closely.
Pharmacology
Mechanism of Action
Verapamil is a non-dihydropyridine calcium channel blocker that inhibits the transmembrane influx of extracellular calcium ions across the membranes of myocardial and vascular smooth muscle cells. This leads to a reduction in myocardial contractility, slowing of AV nodal conduction, and vasodilation of coronary and peripheral arteries, resulting in decreased systemic vascular resistance and blood pressure.
Pharmacokinetics
Absorption:
Bioavailability:
20-35% (due to extensive first-pass metabolism)
Tmax:
7-9 hours (for ER capsules)
FoodEffect:
Food does not significantly affect the extent of absorption but may slightly delay Tmax.
Distribution:
Vd:
1.8-5.0 L/kg
ProteinBinding:
90%
CnssPenetration:
Limited
Elimination:
HalfLife:
5-12 hours (for ER capsules, can be prolonged with chronic use or hepatic impairment)
Clearance:
Not available (highly variable due to first-pass)
ExcretionRoute:
70% renal, 16% fecal
Unchanged:
<4% (renal)
Pharmacodynamics
OnsetOfAction:
Within 1-2 hours (for ER capsules)
PeakEffect:
7-9 hours (for ER capsules)
DurationOfAction:
24 hours (for ER capsules)
Safety & Warnings
Side Effects
Serious Side Effects: Seek Medical Attention Immediately
Although rare, this medication can cause severe and potentially life-threatening side effects. If you experience any of the following symptoms, contact your doctor or seek medical help right away:
Signs of an allergic reaction, such as:
+ Rash
+ Hives
+ Itching
+ Red, swollen, blistered, or peeling skin with or without fever
+ Wheezing
+ Tightness in the chest or throat
+ Trouble breathing, swallowing, or talking
+ Unusual hoarseness
+ Swelling of the mouth, face, lips, tongue, or throat
Signs of liver problems, including:
+ Dark urine
+ Tiredness
+ Decreased appetite
+ Upset stomach or stomach pain
+ Light-colored stools
+ Vomiting
+ Yellow skin or eyes
Slow heartbeat
Abnormal heartbeat that is new or worsening
Severe dizziness or fainting
Shortness of breath, significant weight gain, or swelling in the arms or legs
Other Possible Side Effects
Like all medications, this drug can cause side effects. While many people may not experience any side effects or only minor ones, it's essential to discuss any concerns with your doctor. If you experience any of the following side effects or any other symptoms that bother you or do not go away, contact your doctor:
Dizziness or headache
Constipation
Reporting Side Effects
This list is not exhaustive, and you may experience other side effects. If you have questions or concerns about side effects, contact your doctor. You can also report side effects to the FDA at 1-800-332-1088 or online at https://www.fda.gov/medwatch.
Although rare, this medication can cause severe and potentially life-threatening side effects. If you experience any of the following symptoms, contact your doctor or seek medical help right away:
Signs of an allergic reaction, such as:
+ Rash
+ Hives
+ Itching
+ Red, swollen, blistered, or peeling skin with or without fever
+ Wheezing
+ Tightness in the chest or throat
+ Trouble breathing, swallowing, or talking
+ Unusual hoarseness
+ Swelling of the mouth, face, lips, tongue, or throat
Signs of liver problems, including:
+ Dark urine
+ Tiredness
+ Decreased appetite
+ Upset stomach or stomach pain
+ Light-colored stools
+ Vomiting
+ Yellow skin or eyes
Slow heartbeat
Abnormal heartbeat that is new or worsening
Severe dizziness or fainting
Shortness of breath, significant weight gain, or swelling in the arms or legs
Other Possible Side Effects
Like all medications, this drug can cause side effects. While many people may not experience any side effects or only minor ones, it's essential to discuss any concerns with your doctor. If you experience any of the following side effects or any other symptoms that bother you or do not go away, contact your doctor:
Dizziness or headache
Constipation
Reporting Side Effects
This list is not exhaustive, and you may experience other side effects. If you have questions or concerns about side effects, contact your doctor. You can also report side effects to the FDA at 1-800-332-1088 or online at https://www.fda.gov/medwatch.
Seek Immediate Medical Attention If You Experience:
- Severe dizziness or fainting
- Very slow heart rate (e.g., less than 50 beats per minute)
- Shortness of breath or swelling in your ankles/feet (signs of heart failure)
- Severe constipation that doesn't improve with diet changes
- Chest pain that worsens or doesn't go away
- Yellowing of skin or eyes (jaundice), dark urine, or severe stomach pain (signs of liver problems)
Before Using This Medicine
Before Taking This Medication: Important Information to Share with Your Doctor
It is essential to inform your doctor about the following conditions to ensure safe treatment:
Any allergies you have, including allergies to this medication, its components, or other substances. Be sure to describe the allergic reaction you experienced, including any symptoms that occurred.
Certain health conditions, such as:
+ Heart failure (a weakened heart)
+ Specific types of abnormal heart rhythms, including heart block, Lown-Ganong-Levine syndrome, sick sinus syndrome, or Wolff-Parkinson-White syndrome
+ Low blood pressure
+ A slow heartbeat
Medications you are currently taking, including:
+ Dofetilide, ivabradine, or quinidine
+ Beta blockers like atenolol, metoprolol, or propranolol
+ Disopyramide or flibanserin, if taken within the last 48 hours
If you are breastfeeding, as you should not breastfeed while taking this medication
This list is not exhaustive, and it is crucial to discuss all your medications (prescription, over-the-counter, natural products, and vitamins) and health conditions with your doctor and pharmacist. They will help you determine if it is safe to take this medication with your existing treatments and health status. Never start, stop, or change the dose of any medication without consulting your doctor first.
It is essential to inform your doctor about the following conditions to ensure safe treatment:
Any allergies you have, including allergies to this medication, its components, or other substances. Be sure to describe the allergic reaction you experienced, including any symptoms that occurred.
Certain health conditions, such as:
+ Heart failure (a weakened heart)
+ Specific types of abnormal heart rhythms, including heart block, Lown-Ganong-Levine syndrome, sick sinus syndrome, or Wolff-Parkinson-White syndrome
+ Low blood pressure
+ A slow heartbeat
Medications you are currently taking, including:
+ Dofetilide, ivabradine, or quinidine
+ Beta blockers like atenolol, metoprolol, or propranolol
+ Disopyramide or flibanserin, if taken within the last 48 hours
If you are breastfeeding, as you should not breastfeed while taking this medication
This list is not exhaustive, and it is crucial to discuss all your medications (prescription, over-the-counter, natural products, and vitamins) and health conditions with your doctor and pharmacist. They will help you determine if it is safe to take this medication with your existing treatments and health status. Never start, stop, or change the dose of any medication without consulting your doctor first.
Precautions & Cautions
It is essential to inform all your healthcare providers, including doctors, nurses, pharmacists, and dentists, that you are taking this medication.
When starting this medication, avoid driving and other activities that require alertness until you understand how it affects you. To minimize the risk of dizziness or fainting, get up slowly from a sitting or lying position, and be cautious when climbing stairs.
Follow your doctor's instructions for monitoring your blood pressure and heart rate, and undergo blood tests as recommended. Discuss any concerns or questions with your doctor.
If you have high blood pressure, consult your doctor before taking over-the-counter (OTC) products that may increase blood pressure, such as cough or cold medications, diet pills, stimulants, non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen, and certain natural products or supplements.
Before consuming alcohol, discuss it with your doctor. Additionally, if you regularly drink grapefruit juice or eat grapefruit, talk to your doctor about potential interactions.
If you are 65 years or older, use this medication with caution, as you may be more susceptible to side effects.
If you are pregnant or planning to become pregnant, inform your doctor to discuss the benefits and risks of using this medication during pregnancy.
When starting this medication, avoid driving and other activities that require alertness until you understand how it affects you. To minimize the risk of dizziness or fainting, get up slowly from a sitting or lying position, and be cautious when climbing stairs.
Follow your doctor's instructions for monitoring your blood pressure and heart rate, and undergo blood tests as recommended. Discuss any concerns or questions with your doctor.
If you have high blood pressure, consult your doctor before taking over-the-counter (OTC) products that may increase blood pressure, such as cough or cold medications, diet pills, stimulants, non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen, and certain natural products or supplements.
Before consuming alcohol, discuss it with your doctor. Additionally, if you regularly drink grapefruit juice or eat grapefruit, talk to your doctor about potential interactions.
If you are 65 years or older, use this medication with caution, as you may be more susceptible to side effects.
If you are pregnant or planning to become pregnant, inform your doctor to discuss the benefits and risks of using this medication during pregnancy.
Overdose Information
Overdose Symptoms:
- Severe hypotension (very low blood pressure)
- Profound bradycardia (very slow heart rate)
- High-degree AV block (heart block)
- Asystole (cardiac arrest)
- Cardiogenic shock
- Metabolic acidosis
- Hyperglycemia
- Confusion
- Coma
What to Do:
Call 911 or your local emergency number immediately. For poison control, call 1-800-222-1222. Medical management may include IV calcium, glucagon, vasopressors, atropine, and cardiac pacing.
Drug Interactions
Contraindicated Interactions
- IV beta-blockers (concurrent use due to risk of severe bradycardia, AV block, and myocardial depression)
- Disopyramide (within 48 hours before or 24 hours after verapamil due to risk of severe hypotension and heart failure)
- Dantrolene (IV, due to risk of hyperkalemia and myocardial depression)
- Ivabradine (risk of excessive bradycardia)
Major Interactions
- Beta-blockers (oral, increased risk of bradycardia, AV block, heart failure)
- Digoxin (increased digoxin levels, risk of toxicity)
- Statins (e.g., simvastatin, lovastatin; increased statin levels, risk of myopathy/rhabdomyolysis due to CYP3A4 inhibition)
- Amiodarone (increased risk of bradycardia, AV block, hypotension)
- Flecainide (increased risk of myocardial depression, AV block)
- Quinidine (increased quinidine levels, hypotension)
- Clonidine (increased risk of AV block)
- Midazolam, Triazolam (increased benzodiazepine levels, prolonged sedation)
- Theophylline (increased theophylline levels)
- Carbamazepine (increased carbamazepine levels, toxicity)
- Cyclosporine, Tacrolimus, Sirolimus, Everolimus (increased immunosuppressant levels, toxicity)
- Alpha-blockers (e.g., prazosin, doxazosin; increased risk of hypotension)
- Fentanyl (increased risk of hypotension, respiratory depression)
- Colchicine (increased colchicine levels, toxicity)
Moderate Interactions
- Grapefruit juice (increased verapamil levels)
- Cimetidine (increased verapamil levels)
- Rifampin (decreased verapamil levels)
- Phenobarbital, Phenytoin (decreased verapamil levels)
- Lithium (increased lithium levels, neurotoxicity)
- Buspirone (increased buspirone levels)
- Imipramine (increased imipramine levels)
- Metformin (increased metformin levels)
- Sulfonylureas (increased hypoglycemic effect)
- Local anesthetics (increased risk of toxicity)
Minor Interactions
- Not available (most interactions are moderate to major due to CYP3A4 inhibition and pharmacodynamic effects)
Monitoring
Baseline Monitoring
Blood Pressure (BP)
Rationale: To establish baseline and assess efficacy for hypertension/angina.
Timing: Prior to initiation
Heart Rate (HR)
Rationale: To establish baseline and assess for bradycardia.
Timing: Prior to initiation
Electrocardiogram (ECG)
Rationale: To assess for pre-existing conduction abnormalities (e.g., AV block) and QT interval.
Timing: Prior to initiation
Liver Function Tests (LFTs)
Rationale: Verapamil is extensively metabolized by the liver; assess baseline hepatic function.
Timing: Prior to initiation
Renal Function (SCr, BUN)
Rationale: To assess baseline renal function, though dose adjustment is not typically needed for mild-moderate impairment.
Timing: Prior to initiation
Routine Monitoring
Blood Pressure (BP)
Frequency: Regularly, especially during dose titration and periodically thereafter (e.g., weekly during titration, then monthly/quarterly)
Target: <130/80 mmHg (or individualized target)
Action Threshold: Hypotension (e.g., SBP <90 mmHg or symptomatic), or uncontrolled hypertension
Heart Rate (HR)
Frequency: Regularly, especially during dose titration and periodically thereafter (e.g., weekly during titration, then monthly/quarterly)
Target: 50-90 bpm (or individualized target)
Action Threshold: Bradycardia (<50 bpm or symptomatic), or tachycardia
Electrocardiogram (ECG)
Frequency: Periodically, or if symptoms of bradycardia, AV block, or other arrhythmias develop.
Target: Normal sinus rhythm, PR interval <0.20 sec
Action Threshold: Prolonged PR interval (>0.20 sec), second- or third-degree AV block, or other significant arrhythmias
Symptoms of peripheral edema
Frequency: At each visit
Target: Absence of significant edema
Action Threshold: Significant or bothersome edema
Bowel habits (for constipation)
Frequency: At each visit
Target: Regular bowel movements
Action Threshold: Severe or bothersome constipation
Symptom Monitoring
- Dizziness
- Lightheadedness
- Fainting
- Swelling of ankles/feet (edema)
- Shortness of breath
- Chest pain (worsening angina)
- Palpitations
- Slow heart rate
- Constipation
- Fatigue
Special Patient Groups
Pregnancy
Category C. Use only if the potential benefit justifies the potential risk to the fetus. Verapamil crosses the placenta. Limited human data suggest no increased risk of major birth defects, but animal studies show some adverse effects.
Trimester-Specific Risks:
First Trimester:
Limited human data, animal studies show some embryotoxicity/teratogenicity at high doses.
Second Trimester:
Generally considered safer than first trimester, but still Category C.
Third Trimester:
May cause fetal bradycardia, hypotension, and hyperglycemia. Neonatal adverse effects reported with maternal use near term.
Lactation
L3 (Moderately Safe). Verapamil is excreted into breast milk in small amounts. Monitor breastfed infants for bradycardia, hypotension, and sedation. Consider alternative agents if possible, especially in preterm or neonates.
Infant Risk:
Low to moderate. Potential for bradycardia, hypotension, or sedation in the infant, though typically minimal with usual maternal doses.
Pediatric Use
Extended-release formulations are generally not recommended for pediatric use due to lack of established safety and efficacy. Immediate-release or IV formulations may be used for specific indications (e.g., supraventricular tachycardia) under specialist supervision and careful monitoring.
Geriatric Use
Start with lower doses (e.g., 120 mg ER once daily) and titrate cautiously due to increased sensitivity to hypotensive and bradycardic effects, and potential for reduced hepatic/renal function. Monitor closely for adverse effects, especially constipation and orthostatic hypotension.
Clinical Information
Clinical Pearls
- Verapamil is a potent negative inotrope and dromotrope; use with extreme caution or avoid in patients with left ventricular dysfunction (e.g., heart failure with reduced ejection fraction) or sick sinus syndrome/AV block without a pacemaker.
- Constipation is a very common side effect (up to 40%) and can be severe. Advise patients on dietary fiber, fluids, and potential need for stool softeners.
- Unlike dihydropyridine CCBs (e.g., amlodipine), verapamil has significant effects on cardiac conduction and contractility, making it useful for rate control in atrial fibrillation/flutter and treatment of SVT, but also increasing risk of bradycardia and heart block.
- Extended-release formulations are designed for once-daily dosing and should not be crushed or chewed.
- Monitor for drug interactions, especially with other CYP3A4 substrates (e.g., statins, digoxin, immunosuppressants) and drugs that affect heart rate or conduction (e.g., beta-blockers, amiodarone).
Alternative Therapies
- Other non-dihydropyridine calcium channel blockers (e.g., Diltiazem)
- Dihydropyridine calcium channel blockers (e.g., Amlodipine, Nifedipine, Felodipine) for hypertension/angina
- Beta-blockers (e.g., Metoprolol, Atenolol) for hypertension, angina, rate control
- ACE inhibitors (e.g., Lisinopril, Ramipril) for hypertension
- Angiotensin Receptor Blockers (ARBs) (e.g., Valsartan, Losartan) for hypertension
- Diuretics (e.g., Hydrochlorothiazide, Furosemide) for hypertension
- Other antiarrhythmics (e.g., Amiodarone, Digoxin) for rate/rhythm control in arrhythmias
Cost & Coverage
Average Cost:
Varies widely, typically $10-$50 per 30 capsules (generic)
Generic Available:
Yes
Insurance Coverage:
Tier 1 or Tier 2 (for generic)
General Drug Facts
If your symptoms or health issues persist or worsen, it's essential to contact your doctor for further guidance. To ensure your safety, never share your medication with others or take someone else's medication. Some medications may come with an additional patient information leaflet, so be sure to check with your pharmacist for more details. If you have any questions or concerns about your medication, don't hesitate to reach out to your doctor, nurse, pharmacist, or other healthcare provider. In the event of a suspected overdose, immediately call your local poison control center or seek emergency medical attention. When reporting the incident, be prepared to provide information on the medication taken, the amount, and the time it occurred.