Verapamil ER 240mg Tablets
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
Category C
FDA Approved
Jun 1981
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 helps lower your blood pressure, reduce chest pain (angina), and control certain irregular heart rhythms. It works by blocking calcium from entering heart and blood vessel cells.
How to Use This Medicine
Taking Your Medication Correctly
To 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. Take your medication with food to help your body absorb it properly. If you're taking it once a day, take it in the morning. Swallow the tablet whole - do not chew or crush it. However, some products can be broken in half. If you're unsure whether your specific medication can be broken in half, consult with your doctor.
It's essential to continue taking your medication as directed by your doctor or healthcare provider, even if you start feeling well. This will help you get the full benefit of the treatment and prevent any potential complications.
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. Make sure to store all your medications in a secure location, out of the reach of children and pets.
When disposing of unused or expired medication, do not flush it down the toilet or pour it down the drain unless instructed to do so by your pharmacist or healthcare provider. Instead, 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 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. Take your medication with food to help your body absorb it properly. If you're taking it once a day, take it in the morning. Swallow the tablet whole - do not chew or crush it. However, some products can be broken in half. If you're unsure whether your specific medication can be broken in half, consult with your doctor.
It's essential to continue taking your medication as directed by your doctor or healthcare provider, even if you start feeling well. This will help you get the full benefit of the treatment and prevent any potential complications.
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. Make sure to store all your medications in a secure location, out of the reach of children and pets.
When disposing of unused or expired medication, do not flush it down the toilet or pour it down the drain unless instructed to do so by your pharmacist or healthcare provider. Instead, 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 medication at the same time each day, preferably with food to reduce stomach upset.
- Swallow extended-release tablets whole; do not crush, chew, or break them.
- Avoid grapefruit and grapefruit juice while taking this medication, as it can increase the amount of verapamil in your body and lead to more side effects.
- Monitor your blood pressure and heart rate regularly as advised by your doctor.
- Report any signs of swelling in your ankles or feet, severe dizziness, or a very slow heart rate to your doctor.
- To manage constipation, which is a common side effect, increase fiber intake, drink plenty of fluids, and consider mild laxatives if needed.
- Avoid sudden changes in position (e.g., standing up quickly) to prevent dizziness or lightheadedness.
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:
240 mg orally once daily (ER formulation)
Dose Range:
120 - 480 mg
Condition-Specific Dosing:
hypertension:
Initial: 180 mg or 240 mg ER once daily; titrate up to 240-480 mg once daily. Max: 480 mg/day.
angina:
Initial: 180 mg or 240 mg ER once daily; titrate up to 240-480 mg once daily. Max: 480 mg/day.
supraventricular_tachycardia_prophylaxis:
Not typically used for acute treatment; for prophylaxis, similar to angina/hypertension dosing.
Pediatric Dosing
Neonatal:
Not established (IV formulation used for SVT in specific cases, but not oral ER)
Infant:
Not established (IV formulation used for SVT in specific cases, but not oral ER)
Child:
Not established for hypertension/angina (IV formulation used for SVT in specific cases, but not oral ER)
Adolescent:
Not established for hypertension/angina (IV formulation used for SVT in specific cases, but not oral ER)
Dose Adjustments
Renal Impairment:
Mild:
No specific adjustment needed, monitor for exaggerated effects.
Moderate:
No specific adjustment needed, monitor for exaggerated effects.
Severe:
No specific adjustment needed, monitor for exaggerated effects, as verapamil is primarily metabolized by the liver.
Dialysis:
Not significantly removed by hemodialysis. No specific adjustment needed, but monitor.
Hepatic Impairment:
Mild:
Consider lower initial dose (e.g., 120 mg ER once daily) and titrate cautiously.
Moderate:
Reduce dose by 70-80% of the usual dose. Monitor closely for adverse effects.
Severe:
Reduce dose by 70-80% of the usual dose. Monitor closely for adverse effects. Use with extreme caution.
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 peripheral and coronary arteries. These actions result in decreased systemic vascular resistance, reduced blood pressure, decreased myocardial oxygen demand, and improved coronary blood flow.
Pharmacokinetics
Absorption:
Bioavailability:
20-35% (due to extensive first-pass metabolism)
Tmax:
4-11 hours (for ER formulations)
FoodEffect:
Food does not significantly affect the bioavailability of ER formulations, but may delay Tmax.
Distribution:
Vd:
1.8-5.0 L/kg
ProteinBinding:
90%
CnssPenetration:
Limited (low CSF concentrations, but can cause CNS effects like dizziness)
Elimination:
HalfLife:
5-12 hours (for ER formulations, can be longer with chronic dosing or hepatic impairment)
Clearance:
Not available (highly variable due to first-pass)
ExcretionRoute:
Renal (70%), Fecal (16%)
Unchanged:
<4% (renal)
Pharmacodynamics
OnsetOfAction:
Within 1-2 hours (oral ER)
PeakEffect:
4-11 hours (oral ER)
DurationOfAction:
24 hours (oral ER)
Safety & Warnings
Side Effects
Urgent 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
New or worsening abnormal heartbeat
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
New or worsening abnormal heartbeat
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 lightheadedness
- Fainting
- Very slow heart rate (bradycardia)
- Shortness of breath, especially with exertion or lying down
- New or worsening swelling in the ankles, feet, or legs
- Chest pain or discomfort that is new or worsening
- Signs of liver problems (e.g., yellowing of skin/eyes, dark urine, persistent nausea/vomiting, severe stomach pain)
- Rash or allergic reaction
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.
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 discuss all your medications (prescription, over-the-counter, natural products, and vitamins) and health problems with your doctor and pharmacist. They will help you 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 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.
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 discuss all your medications (prescription, over-the-counter, natural products, and vitamins) and health problems with your doctor and pharmacist. They will help you 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 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 using over-the-counter (OTC) products that may increase blood pressure, such as cough and 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 using over-the-counter (OTC) products that may increase blood pressure, such as cough and 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 (extremely slow heart rate)
- High-degree AV block (heart block)
- Asystole (cardiac arrest)
- 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 fluids, calcium gluconate, atropine, glucagon, vasopressors, and potentially cardiac pacing or extracorporeal membrane oxygenation (ECMO) in severe cases.
Drug Interactions
Contraindicated Interactions
- Ivabradine (risk of severe bradycardia)
- Dantrolene (IV) (risk of hyperkalemia and myocardial depression)
- Colchicine (in patients with renal or hepatic impairment due to increased colchicine levels)
- Strong CYP3A4 inducers (e.g., Rifampin, Phenobarbital, Phenytoin, Carbamazepine) (decreased verapamil levels)
- Beta-blockers (IV) (risk of severe bradycardia, AV block, heart failure)
Major Interactions
- Beta-blockers (oral) (risk of bradycardia, AV block, heart failure)
- Digoxin (increased digoxin levels, risk of toxicity)
- Amiodarone (risk of bradycardia, AV block, hypotension)
- Flecainide (risk of myocardial depression, AV block)
- Disopyramide (risk of severe hypotension, heart failure)
- Statins (e.g., Simvastatin, Lovastatin, Atorvastatin) (increased statin levels, risk of myopathy/rhabdomyolysis)
- Grapefruit juice (increased verapamil levels)
- Strong CYP3A4 inhibitors (e.g., Ketoconazole, Itraconazole, Ritonavir, Clarithromycin) (increased verapamil levels)
- Midazolam, Triazolam (increased benzodiazepine levels)
- Theophylline (increased theophylline levels)
- Cyclosporine, Tacrolimus, Sirolimus, Everolimus (increased immunosuppressant levels)
- Alpha-blockers (e.g., Prazosin, Terazosin) (risk of severe hypotension)
- Fentanyl (risk of severe hypotension, bradycardia)
Moderate Interactions
- Aspirin (increased bleeding risk with high doses of aspirin)
- Cimetidine (increased verapamil levels)
- Lithium (increased lithium levels, neurotoxicity)
- Quinidine (risk of hypotension, pulmonary edema)
- Sulfinpyrazone (decreased verapamil levels)
- Buspirone (increased buspirone levels)
- Imipramine (increased imipramine levels)
- Metformin (increased metformin levels)
- Dabigatran (increased dabigatran levels, increased bleeding risk)
Minor Interactions
- Alcohol (additive hypotensive effects)
- NSAIDs (may reduce antihypertensive effect)
Monitoring
Baseline Monitoring
Blood Pressure (BP)
Rationale: To establish baseline and guide initial dosing.
Timing: Prior to initiation
Heart Rate (HR)
Rationale: To establish baseline and assess for bradycardia risk.
Timing: Prior to initiation
Electrocardiogram (ECG)
Rationale: To assess for pre-existing conduction abnormalities (e.g., AV block, sick sinus syndrome).
Timing: Prior to initiation
Liver Function Tests (LFTs)
Rationale: Verapamil is extensively metabolized by the liver; baseline assessment is important, especially in patients with suspected hepatic impairment.
Timing: Prior to initiation
Renal Function (SCr, BUN)
Rationale: To assess baseline kidney function, though dose adjustment is rarely needed for renal impairment.
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 (<90/60 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 tachycardia.
ECG (PR interval)
Frequency: Periodically, especially with dose increases or concomitant use of other AV nodal blocking agents.
Target: Normal PR interval (<0.20 seconds)
Action Threshold: Significant PR prolongation (>0.24 seconds) or development of AV block.
Liver Function Tests (LFTs)
Frequency: Periodically, especially with long-term therapy or signs of hepatic dysfunction.
Target: Within normal limits
Action Threshold: Significant elevation of liver enzymes (e.g., >3x ULN).
Signs/Symptoms of Heart Failure
Frequency: Regularly
Target: Absence of new or worsening symptoms
Action Threshold: Development of dyspnea, edema, or other signs of heart failure.
Symptom Monitoring
- Dizziness
- Lightheadedness
- Fainting
- Bradycardia (slow heart rate)
- Palpitations
- Shortness of breath
- Swelling in ankles/feet/legs (peripheral edema)
- Constipation
- Headache
- Fatigue
- Chest pain (worsening or new onset)
- Signs of liver dysfunction (e.g., jaundice, dark urine, persistent nausea/vomiting)
Special Patient Groups
Pregnancy
Category C. Verapamil should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Studies in animals have shown adverse effects on the fetus, but there are no adequate and well-controlled studies in pregnant women.
Trimester-Specific Risks:
First Trimester:
Potential for fetal harm based on animal studies; human data limited.
Second Trimester:
Potential for fetal harm based on animal studies; human data limited.
Third Trimester:
Potential for fetal harm based on animal studies; human data limited. May cause fetal bradycardia or hypotension.
Lactation
Verapamil is excreted into breast milk. The American Academy of Pediatrics considers it compatible with breastfeeding, but caution is advised. Monitor the infant for bradycardia, hypotension, and constipation.
Infant Risk:
L3 (Moderately Safe). Low risk of adverse effects in breastfed infants, but monitor for bradycardia, hypotension, and constipation. Consider alternative if infant is premature or has underlying cardiac conditions.
Pediatric Use
Safety and efficacy of oral verapamil (especially ER formulations) have not been established in pediatric patients for hypertension or angina. IV verapamil is used for supraventricular tachycardia (SVT) in children under strict medical supervision due to risk of severe adverse effects.
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. A lower initial dose and slower titration are recommended. Monitor closely for adverse effects, especially constipation and orthostatic hypotension.
Clinical Information
Clinical Pearls
- Verapamil ER should be swallowed whole and not crushed, chewed, or divided, as this can lead to dose dumping and increased side effects.
- Constipation is a very common side effect; advise patients on dietary fiber, fluid intake, and potential use of stool softeners.
- Avoid concomitant use with beta-blockers, especially IV, due to increased risk of severe bradycardia, AV block, and heart failure.
- Grapefruit juice significantly increases verapamil levels; patients should be advised to avoid it.
- Monitor for signs of heart failure, especially in patients with pre-existing left ventricular dysfunction.
- Verapamil can prolong the PR interval; monitor ECG, especially during dose titration or with other AV nodal blocking drugs.
- Patients should be advised to report any signs of dizziness, fainting, or slow heart rate immediately.
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)
- Thiazide diuretics (e.g., Hydrochlorothiazide)
- Loop diuretics (e.g., Furosemide)
- Alpha-1 blockers (e.g., Prazosin, Doxazosin)
- Direct vasodilators (e.g., Hydralazine, Minoxidil)
Cost & Coverage
Average Cost:
$20 - $100 per 30 tablets (generic Verapamil ER 240mg)
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 is 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 it's a good idea to check with your pharmacist for more information. If you have any questions or concerns about this medication, don't hesitate to 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. When seeking help, be prepared to provide details about the overdose, including the medication taken, the amount, and the time it occurred.