Usual Adult Dose for Hypertension

Oral:
Extended release capsules (Verelan PM (R)):

• Initial dose: 200 mg orally once a day at bedtime (usual dose in clinical trials); in rare cases, initial doses of 100 mg orally once a day at bedtime may be warranted in patients who have an increased response to verapamil (e.g., low-weight patients)
• Maintenance dose: Upward titration should be based on therapeutic efficacy and safety evaluated about 24 hours after dosing. If adequate response is not obtained with the initial dose, it may be titrated upward.
• Maximum dose: 400 mg/day

• Initial dose: 180 mg orally once a day at bedtime
• Maintenance dose: If adequate response is not obtained with the initial dose, it may be titrated upward.
• Maximum dose: 480 mg/day

• Initial dose: 80 mg orally 3 times a day; alternatively, 40 mg orally 3 times a day may be considered in patients who might respond to lower doses (e.g., small stature, elderly)
• Maintenance dose: Upward titration should be based on therapeutic efficacy, assessed at the end of the dosing interval.
• Maximum dose: 480 mg/day

• Initial dose: 240 mg orally once a day in the morning (usual dose in clinical trials); alternatively, 120 mg orally once a day in the morning may be warranted in patients who may have an increased response to verapamil (e.g., small stature)
• Maintenance dose: Upward titration should be based on therapeutic efficacy and safety evaluated about 24 hours after dosing. If adequate response is not obtained with the initial dose, it may be titrated upward.
• Maximum dose: 480 mg/day

• Initial dose: 180 mg orally once a day in the morning with food: alternatively, 120 mg orally once a day in the morning with food may be warranted in patients who may have an increased response to verapamil (e.g., small stature)
• Maintenance dose: Upward titration should be based on therapeutic efficacy and safety evaluated weekly, about 24 hours after the previous dose. If adequate response is not obtained with the initial dose, it may be titrated upward.
• Maximum dose: 480 mg/day

• Daily dosages of 360 and 480 mg have been used but there is no evidence that dosages beyond 360 mg provided added effect.

• Management and treatment of essential hypertension

Usual Adult Dose for Supraventricular Tachycardia

Parenteral:

• Initial dose: 5 to 10 mg (0.075 to 0.15 mg/kg) IV bolus over at least 2 minutes
• Repeat dose: 10 mg (0.15 mg/kg) IV (over 2 minutes) 30 minutes after the initial dose if the response is inadequate

• Each dose should be administered over at least 2 minutes under continuous ECG and blood pressure monitoring.

• Rapid conversion to sinus rhythm of paroxysmal supraventricular tachycardia, including those associated with accessory bypass tracts
• Temporary control of rapid ventricular rate in atrial flutter/fibrillation EXCEPT when atrial flutter/fibrillation are associated with accessory bypass tracts

Usual Adult Dose for Angina Pectoris

Oral:
Extended release tablets (Covera HS (R)):

• Initial dose: 180 mg orally once a day at bedtime; if adequate response is not obtained with 180 mg, the dose may be titrated upward.
• Maximum dose: 480 mg/day

• Initial dose: 80 to 120 mg orally 3 times a day; alternatively, 40 mg orally 3 times a day may be warranted in patients who may have an increased response to verapamil (e.g., renal/hepatic impairment, elderly)
• Maintenance dose: Upward titration should be based on therapeutic efficacy and safety evaluated about 8 hours after dosing. Dosage may be increased daily (e.g., patients with unstable angina) or weekly until optimum clinical response is obtained.
• Maximum dose: 480 mg/day

• Management of angina
• Treatment of angina at rest, including vasospastic (Prinzmetal's variant) and unstable (crescendo, pre-infarction) angina
• Treatment of chronic stable (classic effort-associated) angina

Usual Adult Dose for Arrhythmias

Oral:
Immediate release tablets (Calan (R)):

• Chronic atrial fibrillation in digitalized patients: 240 to 320 mg/day orally in 3 or 4 divided doses
• Prophylaxis of paroxysmal supraventricular tachycardia (PSVT) in non-digitalized patients: 240 to 480 mg/day orally in 3 or 4 divided doses

• In general, the maximum effect for any given dosage will be apparent during the first 48 hours of therapy.

• In association with digitalis for the control of ventricular rate at rest and during stress in patients with chronic atrial flutter and /or atrial fibrillation
• Prophylaxis of repetitive PSVT

Usual Geriatric Dose for Hypertension

Extended release capsules (Verelan PM (R)):

• Initial dose: 100 mg orally once a day at bedtime
• Maintenance dose: Upward titration should be based on therapeutic efficacy and safety evaluated about 24 hours after dosing. If adequate response is not obtained with the initial dose, it may be titrated upward.
• Maximum dose: 400 mg/day

• Recommended initial dose: 40 mg orally 3 times a day
• Maintenance dose: Upward titration should be based on therapeutic efficacy (assessed at the end of the dosing interval)
• Maximum dose: 480 mg/day

• Initial dose: 120 mg orally once a day in the morning
• Maintenance dose: Upward titration should be based on therapeutic efficacy and safety evaluated about 24 hours after dosing. If adequate response is not obtained with the initial dose, it may be titrated upward.
• Maximum dose: 480 mg/day

• Initial dose: 120 mg orally once a day in the morning with food
• Maintenance dose: Upward titration should be based on therapeutic efficacy and safety evaluated weekly, about 24 hours after the previous dose. If adequate response is not obtained with the initial dose, it may be titrated upward.
• Maximum dose: 480 mg/day

• An initial reduced dosage may be considered in patients who might respond to lower doses (e.g., elderly patients).
• Immediate release formulation daily dosages of 360 and 480 mg have been used, but there is no evidence that dosages beyond 360 mg provided added effect.

• Management and treatment of essential hypertension

Usual Geriatric Dose for Angina Pectoris

Oral:
Immediate release tablets:

• Initial dose: 40 mg orally 3 times a day
• Maintenance dose: Upward titration should be based on therapeutic efficacy and safety evaluated about 8 hours after dosing. Dosage may be increased daily (e.g., patients with unstable angina) or weekly until optimum clinical response is obtained.
• Maximum dose: 480 mg/day

• An initial reduced dosage may be warranted in patients who may have an increased response to lower doses (e.g., elderly patients).

• Management of angina
• Treatment of angina at rest, including vasospastic (Prinzmetal's variant) and unstable (crescendo, pre-infarction) angina
• Treatment of chronic stable (classic effort-associated) angina

Usual Pediatric Dose for Supraventricular Tachycardia

Parenteral:
Less than 1 year:

• Initial dose: 0.1 to 0.2 mg/kg (usual single dose range 0.75 to 1 mg) IV bolus over at least 2 minutes
• Repeat dose: 0.1 to 0.2 mg/kg (usual single dose range 0.75 to 2 mg) IV 30 minutes after the initial dose if the response is inadequate

• Initial dose: 0.1 to 0.3 mg/kg (usual single dose range: 2 to 5 mg) IV bolus over at least 2 minutes
• Maximum initial dose: 5 mg
• Repeat dose: 0.1 to 0.3 mg/kg (usual single dose range: 2 to 5 mg) IV 30 minutes after the initial dose if the response is inadequate
• Maximum repeat dose: 10 mg

• Each dose should be administered over at least 2 minutes under continuous ECG and blood pressure monitoring.

• Rapid conversion to sinus rhythm of paroxysmal supraventricular tachycardia, including those associated with accessory bypass tracts
• Temporary control of rapid ventricular rate in atrial flutter/fibrillation EXCEPT when atrial flutter/fibrillation are associated with accessory bypass tracts

Renal Dose Adjustments

Oral formulations: Use with caution.
Parenteral formulations: In general, multiple doses in patients with renal impairment should be avoided. If repeated injections are essential, smaller repeat doses are recommended.

Liver Dose Adjustments

Parenteral: In general, multiple doses in patients with liver failure should be avoided. If repeated injections are essential, smaller repeat doses are recommended.

Oral:

• Mild to moderate liver impairment: Use with caution.
• Severe liver impairment: Decrease to approximately 30% of the recommended dose in patients without liver impairment.

Dose Adjustments

Extended release capsules (Verelan PM (R)): If adequate response is not obtained with 200 mg, the dose may be titrated upward in the following manner:
a) 300 mg each evening
b) 400 mg each evening

Extended release tablets (Covera HS (R)): If adequate response is not obtained with 180 mg, the dose may be titrated upward in the following manner:
a) 240 mg each evening
b) 360 mg each evening
c) 480 mg each evening

Sustained release capsules (Verelan (R)): If adequate response is not obtained with 120 mg, the dose may be titrated upward in the following manner:
a) 180 mg in the morning
b) 240 mg in the morning
c) 360 mg in the morning
d) 480 mg in the morning

Sustained release tablets (Calan SR (R), Isoptin SR (R)): If adequate response is not obtained with 180 mg, the dose may be titrated upward in the following manner:
a) 240 mg each morning
b) 180 mg every 12 hours or 240 mg each morning plus 120 mg each evening
c) 240 mg every 12 hours

Immediate release to sustained/extended release formulations: Use the same daily dose for SR/ER forms. Patients may require additional titration of the doses.

Precautions

Safety and efficacy have not been established in patients younger than 18 years (oral formulations).

Consult WARNINGS section for additional precautions.

Dialysis

Oral:

• Hemodialysis: No adjustment recommended.
• Peritoneal dialysis: Data not available

• Data not available

Other Comments

Administration advice:

• The injection formulation should be administered as a slow IV injection over at least 2 minutes, and over at least 3 minutes for elderly patients.
• The sustained release capsule formulation should not be crushed or chewed. The capsules should be swallowed whole or the contents should be sprinkled onto applesauce and eaten.
• The sustained release tablet formulation should be swallowed whole and should not be broken, crushed, or chewed. Since the outer shell of Covera-HS (R) does not dissolve, patients may notice it in their stools.

• The manufacturer product information should be consulted.

• The manufacturer product information should be consulted.

• The manufacturer product information should be consulted.

• Sustained release formulations may differ in pharmacokinetic behavior and should not be considered interchangeable with equivalent doses (e.g., Veracaps SR (R)).
• The antihypertensive effects of verapamil are evident within the first week of therapy.
• Patients with liver impairment may achieve therapeutic levels with one-third of the recommended daily dose in healthy patients.

• Blood pressure, especially in patients given the IV formulation and in patients with hypertension
• ECG, especially in patients with renal, hepatic, or cardiac disorders and/or those given the IV formulation
• Liver function tests

• Warn patients to avoid abrupt discontinuation of this drug.
• Patients should be advised to report all concurrent prescription and nonprescription medications or herbal products they are taking.
• Tell patients to immediately report any signs/symptoms of liver injury or new/worsening heart failure.
• Inform patients that this drug may cause drowsiness, and they should avoid driving or operating machinery until the full effects of the drug are known.
• Patients should be advised to speak to a healthcare provider if they become pregnant, intend to become pregnant, or are breastfeeding.