Verapamil 2.5mg/ml Inj, 5x2ml Vial
It is used to treat certain types of abnormal heartbeats.It may be given to you for other reasons. Talk with the doctor.
Drug Class
Antiarrhythmic, Antihypertensive
Pharmacologic Class
Calcium Channel Blocker, Non-dihydropyridine
Pregnancy Category
Category C
FDA Approved
Jun 1981
DEA Schedule
Not Controlled
Overview
What is this medicine?
Verapamil is a medication given by injection, usually in a hospital setting, to quickly slow down a very fast or irregular heartbeat. It works by relaxing blood vessels and slowing down the electrical signals in your heart, which helps your heart beat more regularly and efficiently.
How to Use This Medicine
To use this medication correctly, follow your doctor's instructions and carefully read all accompanying information. Administer the medication as directed, which typically involves intravenous infusion over a specified period.
For proper storage and disposal, consult with your doctor, nurse, or pharmacist to determine the best approach if you need to store the medication at home.
If you miss a dose, contact your doctor promptly to receive guidance on the next steps to take.
For proper storage and disposal, consult with your doctor, nurse, or pharmacist to determine the best approach if you need to store the medication at home.
If you miss a dose, contact your doctor promptly to receive guidance on the next steps to take.
Lifestyle & Tips
- This medication is typically administered in an acute care setting, so lifestyle modifications are not directly applicable during administration.
- Patients should follow their doctor's advice regarding diet, exercise, and other medications once discharged.
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:
Initial: 5-10 mg IV bolus over 2 minutes. May repeat 10 mg IV 30 minutes after initial dose if inadequate response. Maintenance: Not typically used as continuous infusion for acute SVT, but can be considered in specific situations (e.g., for rate control in atrial fibrillation/flutter) at 0.005 mg/kg/min (350 mcg/min) for up to 24 hours after initial bolus.
Dose Range:
5 - 10 mg
Condition-Specific Dosing:
Supraventricular Tachyarrhythmias (SVT):
Initial: 5-10 mg IV over 2 minutes. If inadequate response, 10 mg IV 30 minutes after initial dose. Elderly or patients with impaired hepatic function: Administer over 3 minutes.
Atrial Fibrillation/Flutter (rate control):
Initial: 5-10 mg IV over 2 minutes. If inadequate response, 10 mg IV 30 minutes after initial dose. Continuous infusion (rarely used for acute rate control): 0.005 mg/kg/min (350 mcg/min) for up to 24 hours after initial bolus.
Pediatric Dosing
Neonatal:
Not established (use with extreme caution due to risk of severe hypotension and bradycardia).
Infant:
0.1-0.2 mg/kg (max 2 mg) IV over 2 minutes. May repeat in 30 minutes if needed (max 10 mg total). Closely monitor ECG and BP.
Child:
0.1-0.2 mg/kg (max 5 mg) IV over 2 minutes. May repeat in 30 minutes if needed (max 10 mg total). Closely monitor ECG and BP.
Adolescent:
0.1-0.2 mg/kg (max 5 mg) IV over 2 minutes. May repeat in 30 minutes if needed (max 10 mg total). Closely monitor ECG and BP.
Dose Adjustments
Renal Impairment:
Mild:
No specific dose adjustment required, but monitor closely.
Moderate:
No specific dose adjustment required, but monitor closely.
Severe:
No specific dose adjustment required, but monitor closely. Verapamil is not significantly dialyzable.
Dialysis:
Not significantly removed by hemodialysis. No supplemental dose needed post-dialysis. Monitor for exaggerated effects.
Hepatic Impairment:
Mild:
Consider lower initial dose (e.g., 2.5-5 mg) and slower administration (over 3 minutes).
Moderate:
Reduce dose by 30-50% and administer over 3 minutes. Monitor closely for adverse effects.
Severe:
Reduce dose by 50-75% and administer over 3 minutes. Use with extreme caution and close monitoring.
Pharmacology
Mechanism of Action
Verapamil is a non-dihydropyridine calcium channel blocker. It inhibits the influx of extracellular calcium ions across the membranes of myocardial and vascular smooth muscle cells, as well as cells of the cardiac conduction system (SA and AV nodes). This leads to: 1) Dilation of coronary and peripheral arteries, reducing afterload and myocardial oxygen demand. 2) Decreased myocardial contractility (negative inotropy). 3) Slowing of SA node automaticity and AV nodal conduction, prolonging the PR interval and refractory period, which is crucial for terminating re-entrant supraventricular tachycardias and controlling ventricular rate in atrial fibrillation/flutter.
Pharmacokinetics
Absorption:
Bioavailability:
Not applicable (IV administration)
Tmax:
Not applicable (IV administration)
FoodEffect:
Not applicable (IV administration)
Distribution:
Vd:
1.8-5.5 L/kg (IV)
ProteinBinding:
90%
CnssPenetration:
Limited
Elimination:
HalfLife:
2-5 hours (IV, single dose); 4.5-12 hours (oral, chronic dosing due to saturation of hepatic enzymes)
Clearance:
0.5-1.5 L/min (IV)
ExcretionRoute:
70% renal (as metabolites), 16% fecal
Unchanged:
3-4% (renal)
Pharmacodynamics
OnsetOfAction:
1-5 minutes (IV)
PeakEffect:
3-5 minutes (IV)
DurationOfAction:
10-20 minutes (IV, single dose); up to 6 hours (oral)
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 lightheadedness
- Fainting
- Slow or irregular heartbeat
- Shortness of breath
- Swelling in the ankles or feet
- Chest pain
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:
Any allergies you have, including allergies to this medication, its components, or other substances, such as foods or drugs. Describe the allergic reaction you experienced, including the symptoms that occurred.
Certain health conditions, including:
+ Heart failure (a weakened heart)
+ Specific types of abnormal heart rhythms, such as 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 problems with your doctor and pharmacist. They will help determine if it is safe to take this medication with your other medications and health conditions. Never start, stop, or change the dose of any medication without consulting your doctor.
It is essential to inform your doctor about the following:
Any allergies you have, including allergies to this medication, its components, or other substances, such as foods or drugs. Describe the allergic reaction you experienced, including the symptoms that occurred.
Certain health conditions, including:
+ Heart failure (a weakened heart)
+ Specific types of abnormal heart rhythms, such as 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 problems with your doctor and pharmacist. They will help determine if it is safe to take this medication with your other medications and health conditions. Never start, stop, or change the dose of any medication without consulting your doctor.
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, be cautious when driving or performing tasks that require your full attention, as it may affect your alertness. To minimize the risk of dizziness or fainting, get up slowly from a sitting or lying position, and be careful when navigating stairs.
Follow your doctor's instructions for monitoring your blood pressure and heart rate, and undergo blood tests as recommended. If you have high blood pressure, consult your doctor before taking any 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 aids.
Discuss your alcohol consumption with your doctor before drinking, and if you regularly consume grapefruit juice or eat grapefruit, inform your doctor as well.
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, consult your doctor to discuss the potential benefits and risks of using this medication during pregnancy.
When starting this medication, be cautious when driving or performing tasks that require your full attention, as it may affect your alertness. To minimize the risk of dizziness or fainting, get up slowly from a sitting or lying position, and be careful when navigating stairs.
Follow your doctor's instructions for monitoring your blood pressure and heart rate, and undergo blood tests as recommended. If you have high blood pressure, consult your doctor before taking any 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 aids.
Discuss your alcohol consumption with your doctor before drinking, and if you regularly consume grapefruit juice or eat grapefruit, inform your doctor as well.
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, consult your doctor to discuss the potential benefits and risks of using this medication during pregnancy.
Overdose Information
Overdose Symptoms:
- Profound hypotension (low blood pressure)
- Bradycardia (very slow heart rate)
- High-degree AV block (heart block)
- Asystole (cardiac arrest)
- Cardiogenic shock
- Metabolic acidosis
- Hyperglycemia
- Confusion
- Coma
What to Do:
Immediate medical attention is required. Treatment is supportive and may include IV calcium gluconate/chloride, atropine, vasopressors (e.g., norepinephrine), glucagon, high-dose insulin-glucose therapy, and cardiac pacing. Call 1-800-222-1222 (Poison Control) for further guidance.
Drug Interactions
Contraindicated Interactions
- Beta-blockers (IV, concurrent use or within a few hours): Risk of severe bradycardia, AV block, and myocardial depression.
- Disopyramide: Should not be administered within 48 hours before or 24 hours after verapamil due to potential for severe hypotension and cardiac arrest.
- Dantrolene (IV): Risk of hyperkalemia and myocardial depression.
- Ivabradine: Risk of excessive bradycardia.
- Colchicine (in patients with renal or hepatic impairment): Increased colchicine toxicity.
Major Interactions
- Digoxin: Verapamil increases serum digoxin levels by 50-75%. Reduce digoxin dose by 50% and monitor levels.
- Flecainide: Additive negative inotropic effects.
- Amiodarone: Additive effects on heart rate and AV conduction.
- Statins (e.g., Simvastatin, Lovastatin, Atorvastatin): Verapamil is a CYP3A4 inhibitor, increasing statin levels and risk of myopathy/rhabdomyolysis. Use lower statin doses or alternative statins (e.g., Pravastatin, Rosuvastatin).
- CYP3A4 inhibitors (e.g., Ketoconazole, Ritonavir, Clarithromycin): Increase verapamil levels, increasing risk of adverse effects.
- CYP3A4 inducers (e.g., Rifampin, Phenobarbital, Phenytoin, St. John's Wort): Decrease verapamil levels, reducing efficacy.
- Neuromuscular blockers (e.g., Vecuronium, Pancuronium): Verapamil may potentiate their effects, requiring lower doses.
- Oral Antidiabetics (e.g., Glyburide, Metformin): Verapamil may alter glucose tolerance.
- Theophylline: Verapamil may increase theophylline levels.
Moderate Interactions
- Alpha-blockers (e.g., Prazosin, Terazosin): Additive hypotensive effects.
- Clonidine: Additive effects on heart rate and AV conduction.
- Lithium: Verapamil may decrease lithium levels.
- Carbamazepine: Verapamil may increase carbamazepine levels, leading to toxicity.
- Cyclosporine, Tacrolimus, Sirolimus, Everolimus: Verapamil may increase levels of these immunosuppressants.
- Buspirone: Verapamil may increase buspirone levels.
- Midazolam, Triazolam: Verapamil may increase levels of these benzodiazepines.
- Quinidine: May cause hypotension in patients with hypertrophic cardiomyopathy.
Minor Interactions
- Aspirin: No significant interaction.
- NSAIDs: May reduce antihypertensive effect, but generally not clinically significant for acute IV use.
Monitoring
Baseline Monitoring
Electrocardiogram (ECG)
Rationale: To assess baseline rhythm, PR interval, QRS duration, and identify pre-existing conduction abnormalities (e.g., AV block, WPW) that are contraindications.
Timing: Prior to administration.
Blood Pressure (BP)
Rationale: To establish baseline and identify hypotension, a common adverse effect.
Timing: Prior to administration.
Heart Rate (HR)
Rationale: To establish baseline and monitor for bradycardia.
Timing: Prior to administration.
Left Ventricular Function
Rationale: To assess for severe LV dysfunction or cardiogenic shock, which are contraindications.
Timing: Clinical assessment prior to administration.
Routine Monitoring
Electrocardiogram (ECG) - continuous monitoring
Frequency: Continuously during and after administration for at least 6 hours or until stable.
Target: Normal sinus rhythm or controlled ventricular rate (e.g., <100 bpm in AF/AFL); PR interval <0.20 seconds (unless therapeutic prolongation is desired and tolerated); absence of new AV block.
Action Threshold: Development of 2nd or 3rd degree AV block, significant bradycardia (<50 bpm), QRS widening, or signs of accessory pathway conduction (e.g., pre-excitation).
Blood Pressure (BP)
Frequency: Every 5 minutes during administration, then every 15 minutes for the first hour, then every 30-60 minutes until stable.
Target: Maintain systolic BP >90-100 mmHg (or patient's baseline).
Action Threshold: Systolic BP <90 mmHg or symptomatic hypotension.
Heart Rate (HR)
Frequency: Continuously during and after administration.
Target: Maintain HR >50 bpm (unless desired therapeutic effect for SVT is lower and tolerated).
Action Threshold: HR <50 bpm or symptomatic bradycardia.
Fluid Status/Urine Output
Frequency: As clinically indicated, especially in patients with heart failure.
Target: Adequate urine output.
Action Threshold: Signs of fluid overload or decreased urine output.
Symptom Monitoring
- Dizziness
- Lightheadedness
- Syncope
- Chest pain
- Shortness of breath
- Palpitations
- Fatigue
- Swelling in ankles/feet
Special Patient Groups
Pregnancy
Use in pregnancy only if the potential benefit justifies the potential risk to the fetus. Verapamil crosses the placenta. Category C.
Trimester-Specific Risks:
First Trimester:
Limited data, but animal studies show some evidence of embryotoxicity/teratogenicity at high doses. Avoid if possible.
Second Trimester:
May be used if clinically indicated, with careful monitoring.
Third Trimester:
May cause fetal bradycardia, hypotension, and acidosis. Use with caution, especially near term.
Lactation
Verapamil is excreted into breast milk. The American Academy of Pediatrics considers it compatible with breastfeeding, but monitor infant for bradycardia, hypotension, and sedation. L3 (Moderately Safe).
Infant Risk:
Low to moderate risk. Monitor for bradycardia, hypotension, and sedation. Consider alternative if infant is premature or has underlying cardiac issues.
Pediatric Use
Use with extreme caution, especially in infants, due to increased risk of severe hypotension and bradycardia. Dosing is weight-based and requires careful titration and continuous monitoring. Contraindicated in infants with Wolff-Parkinson-White (WPW) syndrome and atrial fibrillation/flutter.
Geriatric Use
Elderly patients may be more sensitive to the hypotensive and bradycardic effects of verapamil due to age-related decreases in hepatic and renal function. Start with lower doses (e.g., 2.5-5 mg) and administer over 3 minutes. Monitor closely for adverse effects.
Clinical Information
Clinical Pearls
- Always administer IV verapamil slowly (over 2-3 minutes) to minimize the risk of hypotension and bradycardia.
- Ensure continuous ECG and blood pressure monitoring during and after administration.
- Have resuscitation equipment and medications (e.g., calcium gluconate/chloride, atropine, vasopressors) readily available.
- Verapamil is contraindicated in patients with wide complex tachycardias of unknown origin, as it can cause hemodynamic collapse in patients with ventricular tachycardia.
- Absolutely contraindicated in patients with atrial fibrillation/flutter and an accessory bypass tract (e.g., WPW syndrome) due to the risk of accelerating conduction down the accessory pathway, leading to ventricular fibrillation.
- Avoid concurrent IV beta-blocker administration or within a few hours of verapamil due to synergistic negative cardiac effects.
- Calcium gluconate/chloride can be used to reverse some of the cardiac depressant effects of verapamil in overdose or severe adverse reactions.
Alternative Therapies
- Adenosine (first-line for stable SVT)
- Diltiazem (another non-dihydropyridine CCB, similar indications)
- Beta-blockers (e.g., Metoprolol, Esmolol - for rate control in AF/AFL or certain SVTs, but contraindicated with verapamil)
- Digoxin (for chronic rate control in AF/AFL, less effective for acute SVT termination)
- Electrical cardioversion (for unstable tachyarrhythmias or refractory stable tachyarrhythmias)
Cost & Coverage
Average Cost:
Not available (varies widely by hospital contract and GPO) per 2ml vial
Generic Available:
Yes
Insurance Coverage:
Tier 1 or 2 (generic)
General Drug Facts
If your symptoms or health problems persist or worsen, it is essential to contact your doctor promptly. To ensure safe use, never share your medication with others, and do not take medication prescribed for someone else. Store all medications in a secure location, out of reach of children and pets, to prevent accidental ingestion. Dispose of unused or expired medications properly; do not flush them down the toilet or pour them down the drain unless instructed to do so by a healthcare professional or pharmacist. If you are unsure about the correct disposal method, consult your pharmacist, as they can provide guidance or inform you about potential drug take-back programs in your area. Some medications may come with an additional patient information leaflet, so it is a good idea to check with your pharmacist. If you have any questions or concerns about your medication, discuss them with 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. Be prepared to provide information about the medication taken, the amount, and the time it was taken to ensure prompt and appropriate care.