Verapamil 240mg 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
Calcium Channel Blocker (Non-dihydropyridine)
Pregnancy Category
C
FDA Approved
Sep 1986
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 makes it easier for your heart to pump blood, which can lower high blood pressure, reduce chest pain (angina), and help control certain irregular heart rhythms.
How to Use This Medicine
Taking Your Medication Correctly
To ensure you get the most benefit from your medication, follow your doctor's instructions 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, consult with your pharmacist.
When taking your medication:
Swallow the tablet or capsule whole. Do not chew or crush it.
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. Avoid mixing the medication with hot applesauce.
Continue taking your medication as directed by your doctor or healthcare provider, even if you start to feel better.
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.
Keep it in a dry place, away from the bathroom.
Store all medications in a secure location, out of the reach of children and pets.
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 your pharmacist. Check with your pharmacist for guidance on the best way to dispose of your medication. You may also want to explore drug take-back programs in your area.
What to Do If You Miss a Dose
If you miss a dose, 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 resume 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 ensure you get the most benefit from your medication, follow your doctor's instructions 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, consult with your pharmacist.
When taking your medication:
Swallow the tablet or capsule whole. Do not chew or crush it.
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. Avoid mixing the medication with hot applesauce.
Continue taking your medication as directed by your doctor or healthcare provider, even if you start to feel better.
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.
Keep it in a dry place, away from the bathroom.
Store all medications in a secure location, out of the reach of children and pets.
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 your pharmacist. Check with your pharmacist for guidance on the best way to dispose of your medication. You may also want to explore drug take-back programs in your area.
What to Do If You Miss a Dose
If you miss a dose, 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 resume 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 the capsule whole; do not crush, chew, or divide extended-release capsules.
- Take with food to reduce stomach upset and improve absorption.
- Avoid grapefruit and grapefruit juice while taking this medication, as it can increase the amount of verapamil in your body and lead to side effects.
- Limit alcohol consumption, as it can increase the blood pressure-lowering effects.
- Maintain a healthy diet, low in sodium and saturated fats, and engage in regular exercise 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 extended-release capsule orally once daily
Dose Range:
180 - 480 mg
Condition-Specific Dosing:
hypertension:
Initial: 180 mg ER once daily; Titrate: May increase to 240 mg, 360 mg, or 480 mg once daily. Max: 480 mg/day.
angina:
Initial: 180 mg ER once daily; Titrate: May increase to 240 mg, 360 mg, or 480 mg once daily. Max: 480 mg/day.
Pediatric Dosing
Neonatal:
Not established
Infant:
Not established
Child:
Not established (Oral ER formulations generally not recommended for routine pediatric use; IV verapamil used for SVT in specific cases)
Adolescent:
Not established
Dose Adjustments
Renal Impairment:
Mild:
No specific adjustment, use with caution.
Moderate:
No specific adjustment, use with caution.
Severe:
Use with caution, monitor for exaggerated effects. Consider lower doses.
Dialysis:
Not dialyzable. Use with caution, monitor for exaggerated effects.
Hepatic Impairment:
Mild:
Consider lower initial dose (e.g., 120 mg ER once daily).
Moderate:
Reduce dose significantly (e.g., 20-30% of normal dose). Titrate slowly with careful monitoring.
Severe:
Contraindicated or use with extreme caution and significant dose reduction (e.g., 20-30% of normal dose).
Confidence:
Medium
Pharmacology
Mechanism of Action
Verapamil is a non-dihydropyridine calcium channel blocker that inhibits the transmembrane influx of calcium ions into cardiac and vascular smooth muscle cells. This leads to a reduction in myocardial contractility, slowing of SA and AV nodal conduction, and peripheral and coronary vasodilation. These actions result in decreased heart rate, decreased systemic vascular resistance, and reduced myocardial oxygen demand.
Pharmacokinetics
Absorption:
Bioavailability:
20-35% (due to extensive first-pass metabolism)
Tmax:
4-12 hours (for extended-release formulations)
FoodEffect:
Food can slightly increase bioavailability and reduce peak plasma concentrations, but overall absorption is not significantly affected. Should be taken with food.
Distribution:
Vd:
4.5-7 L/kg
ProteinBinding:
Approximately 90%
CnssPenetration:
Limited
Elimination:
HalfLife:
8-15 hours (multiple doses, extended-release)
Clearance:
Not available (highly variable due to first-pass)
ExcretionRoute:
Renal (approximately 70%), Fecal (approximately 16%)
Unchanged:
Approximately 3-4% (renal)
Pharmacodynamics
OnsetOfAction:
2-5 hours (oral extended-release)
PeakEffect:
4-12 hours (oral extended-release)
DurationOfAction:
24 hours (oral extended-release)
Confidence:
Medium
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 unusual 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 for medical advice. 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 unusual 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 for medical advice. 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 (less than 50 beats per minute)
- Shortness of breath or swelling in your ankles/feet (signs of heart failure)
- Severe constipation
- Chest pain (worsening or new)
- Yellowing of skin or eyes (jaundice), dark urine, or persistent nausea/vomiting (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:
Any allergies you have, including allergies to this medication, its components, or other substances, such as foods or drugs. Be sure to describe the allergic reaction you experienced, including any symptoms that occurred.
Certain health conditions, including:
+ Heart failure (a weak 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
If you have taken disopyramide or flibanserin 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 inform your doctor and pharmacist about all your medications, including prescription and over-the-counter drugs, natural products, and vitamins, as well as any health problems you may have. This will help ensure your safety while taking this medication. Never start, stop, or change the dose of any medication without first 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. Be sure to describe the allergic reaction you experienced, including any symptoms that occurred.
Certain health conditions, including:
+ Heart failure (a weak 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
If you have taken disopyramide or flibanserin 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 inform your doctor and pharmacist about all your medications, including prescription and over-the-counter drugs, natural products, and vitamins, as well as any health problems you may have. This will help ensure your safety while taking this medication. Never start, stop, or change the dose of any medication without first 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, 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 aids.
Before consuming alcohol, discuss its potential effects 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, consult 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 aids.
Before consuming alcohol, discuss its potential effects 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, consult 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)
- Asystole (cardiac arrest)
- AV block (heart block)
- Cardiogenic shock
- Metabolic acidosis
- Hyperglycemia
- Confusion
- Coma
What to Do:
Seek immediate medical attention. Call 911 or your local emergency number. For poison control, call 1-800-222-1222. Treatment may include IV calcium, vasopressors, atropine, glucagon, and cardiac pacing.
Drug Interactions
Contraindicated Interactions
- IV Beta-blockers (concurrent use or within a few hours)
- Disopyramide (within 48 hours before or 24 hours after verapamil)
- Flecainide
- Dantrolene (IV)
- Ivabradine
- Quinidine (in patients with hypertrophic cardiomyopathy)
Major Interactions
- Digoxin (increases digoxin levels, reduce digoxin dose by 50%)
- Amiodarone (additive bradycardia/AV block)
- Statins (e.g., simvastatin, lovastatin - increased statin levels due to CYP3A4 inhibition)
- Cyclosporine (increased cyclosporine levels)
- Tacrolimus (increased tacrolimus levels)
- Carbamazepine (increased carbamazepine levels)
- Rifampin (decreased verapamil levels)
- Grapefruit juice (increases verapamil levels)
- Clonidine (additive bradycardia/hypotension)
- Fentanyl (severe bradycardia)
Moderate Interactions
- Other antihypertensives (additive hypotensive effects)
- Antiarrhythmics (e.g., propafenone, sotalol - additive effects on cardiac conduction)
- Theophylline (increased theophylline levels)
- Cimetidine (increased verapamil levels)
- Phenobarbital (decreased verapamil levels)
- Lithium (increased lithium levels)
- Neuromuscular blockers (potentiates effects)
Monitoring
Baseline Monitoring
Blood Pressure (BP)
Rationale: To establish baseline and guide initial dosing for hypertension/angina.
Timing: Prior to initiation
Heart Rate (HR)
Rationale: To establish baseline and assess for bradycardia risk.
Timing: Prior to initiation
Electrocardiogram (ECG) - PR interval
Rationale: To assess baseline cardiac conduction and identify pre-existing AV block.
Timing: Prior to initiation
Liver Function Tests (LFTs)
Rationale: Verapamil is extensively metabolized by the liver; to assess baseline hepatic function.
Timing: Prior to initiation
Renal Function (BUN, Creatinine)
Rationale: To assess baseline renal function as a significant portion is renally excreted.
Timing: Prior to initiation
Routine Monitoring
Blood Pressure (BP)
Frequency: Regularly, especially during dose titration and periodically thereafter.
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.
Target: 50-90 bpm (or individualized target)
Action Threshold: Bradycardia (<50 bpm or symptomatic), or significant change from baseline.
Electrocardiogram (ECG) - PR interval
Frequency: Periodically, especially with dose increases or in patients with conduction abnormalities.
Target: Normal PR interval (<0.20 seconds)
Action Threshold: Significant PR prolongation or development of AV block.
Liver Function Tests (LFTs)
Frequency: Periodically, especially in patients with hepatic impairment or long-term therapy.
Target: Within normal limits
Action Threshold: Significant elevation of liver enzymes.
Signs of Peripheral Edema
Frequency: Regularly
Target: Absence of significant edema
Action Threshold: Development of new or worsening peripheral edema.
Symptom Monitoring
- Dizziness
- Lightheadedness
- Fatigue
- Constipation
- Headache
- Nausea
- Peripheral edema (swelling of ankles/feet)
- Shortness of breath
- Chest pain (worsening angina)
- Palpitations
- Fainting spells
Special Patient Groups
Pregnancy
Category C. Use during pregnancy only if the potential benefit justifies the potential risk to the fetus. Verapamil crosses the placenta.
Trimester-Specific Risks:
First Trimester:
Limited human data, animal studies show adverse effects at high doses. Use only if clearly needed.
Second Trimester:
Limited human data. Use only if clearly needed.
Third Trimester:
Limited human data. May cause fetal bradycardia or hypotension. Use only if clearly needed.
Lactation
Verapamil is excreted into breast milk. While the amount is small, monitor breastfed infants for signs of bradycardia, hypotension, or sedation. Use with caution, or consider an alternative.
Infant Risk:
L3 (Moderately safe) - Potential for minor adverse effects; monitor infant.
Pediatric Use
Safety and effectiveness of oral extended-release verapamil in pediatric patients have not been established. Not recommended for routine use in children. IV verapamil is used for specific indications like supraventricular tachycardia in a controlled setting.
Geriatric Use
Start with lower doses (e.g., 120 mg ER once daily) and titrate slowly due to increased sensitivity to hypotensive and bradycardic effects, reduced hepatic clearance, and potential for increased adverse reactions (e.g., constipation). Monitor closely for adverse effects.
Clinical Information
Clinical Pearls
- Verapamil ER should be swallowed whole and not crushed, chewed, or divided, as this can lead to rapid release of the drug and potentially dangerous side effects.
- Constipation is a very common side effect; advise patients on dietary fiber, fluid intake, and stool softeners if necessary.
- Avoid concurrent use with IV beta-blockers due to risk of severe bradycardia, AV block, and myocardial depression.
- Monitor for signs of heart failure, especially in patients with pre-existing left ventricular dysfunction.
- Grapefruit juice significantly increases verapamil levels; patients should be advised to avoid it completely.
Alternative Therapies
- Other non-dihydropyridine calcium channel blockers (e.g., Diltiazem)
- Dihydropyridine calcium channel blockers (e.g., Amlodipine, Nifedipine)
- Beta-blockers (e.g., Metoprolol, Atenolol)
- ACE inhibitors (e.g., Lisinopril, Enalapril)
- Angiotensin Receptor Blockers (ARBs) (e.g., Valsartan, Losartan)
- Diuretics (e.g., Hydrochlorothiazide, Furosemide)
- Other antiarrhythmics (e.g., Amiodarone, Digoxin for rate control)
Cost & Coverage
Average Cost:
$30 - $60 per 30 capsules (generic 240mg ER)
Generic Available:
Yes
Insurance Coverage:
Tier 1 or Tier 2 (Generic)
General Drug Facts
If your symptoms or health issues persist or worsen, it is essential to contact your doctor promptly. To ensure safe and effective treatment, never share your medication with others or take someone else's medication. Some medications may come with an additional patient information leaflet, so it's a good idea to check with your pharmacist for more information. 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 seeking help, be prepared to provide details about the medication taken, the amount, and the time it happened.