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Verapamil


Pronunciation

 (ver AP a mil)


U.S. Brand Names

 Calan®; Calan® SR; Covera-HS®; Isoptin® SR; Verelan®; Verelan® PM


Synonyms

 Iproveratril Hydrochloride; Verapamil Hydrochloride


Generic Available

 Yes


Canadian Brand Names

 Alti-Verapamil; Apo-Verap®; Calan®; Chronovera®; Covera®; Gen-Verapamil; Gen-Verapamil SR; Isoptin®; Isoptin® I.V.; Isoptin® SR; Novo-Veramil; Novo-Veramil SR; Nu-Verap


Use

 Orally for treatment of angina pectoris (vasospastic, chronic stable, unstable) and hypertension; I.V. for supraventricular tachyarrhythmias (PSVT, atrial fibrillation, atrial flutter)


Use - Unlabeled/Investigational

 Migraine; hypertrophic cardiomyopathy; bipolar disorder (manic manifestations)


Pregnancy Risk Factor

 C


Pregnancy Implications

 Use in pregnancy only when clearly needed and when the benefits outweigh the potential risk to the fetus. Crosses the placenta. One report of suspected heart block when used to control fetal supraventricular tachycardia. May exhibit tocolytic effects.


Lactation

 Enters breast milk (small amounts)/not recommended


Contraindications

 Hypersensitivity to verapamil or any component of the formulation; severe left ventricular dysfunction; hypotension (systolic pressure <90 mm Hg) or cardiogenic shock; sick sinus syndrome (except in patients with a functioning artificial pacemaker); second- or third-degree AV block (except in patients with a functioning artificial pacemaker); atrial flutter or fibrillation and an accessory bypass tract (WPW, Lown-Ganong-Levine syndrome)


Warnings/Precautions

 Avoid use in heart failure; can exacerbate condition. Can cause hypotension. Rare increases in liver function tests can be observed. Can cause first-degree AV block or sinus bradycardia. Other conduction abnormalities are rare. Use caution when using verapamil together with a beta-blocker. Avoid use of I.V. verapamil with an I.V. beta-blocker; can result in asystole. Use caution in patients with hypertrophic cardiomyopathy (IHSS). Use with caution in patients with attenuated neuromuscular transmission (Duchenne's muscular dystrophy, myasthenia gravis). Adjust the dose in severe renal dysfunction and hepatic dysfunction. Verapamil significantly increases digoxin serum concentrations (adjust digoxin's dose). May prolong recovery from nondepolarizing neuromuscular-blocking agents.


Adverse Reactions

>10%: Gastrointestinal: Gingival hyperplasia (19%)

1% to 10%:

Cardiovascular: Bradycardia (1.4% oral, 1.2% I.V.); first-, second-, or third-degree AV block (1.2% oral, unknown I.V.); CHF (1.8% oral); hypotension (2.5% oral, 3% I.V.); peripheral edema (1.9% oral), symptomatic hypotension (1.5% I.V.); severe tachycardia (1% I.V.)

Central nervous system: Dizziness (3.3% oral, 1.2% I.V.), fatigue (1.7% oral), headache (2.2% oral, 1.2% I.V.)

Dermatologic: Rash (1.2% oral)

Gastrointestinal: Constipation (12% up to 42% in clinical trials), nausea (2.7% oral, 0.9% I.V.)

Respiratory: Dyspnea (1.4% oral)

Oral: <1% (Limited to important or life-threatening): Angina, atrioventricular dissociation, chest pain, claudication, MI, palpitation, purpura (vasculitis), syncope, diarrhea, dry mouth, gastrointestinal distress, gingival hyperplasia, ecchymosis, bruising, cerebrovascular accident, confusion, equilibrium disorders, insomnia, muscle cramps, paresthesia, psychotic symptoms, shakiness, somnolence, arthralgia, rash, exanthema, hair loss, hyperkeratosis, macules, diaphoresis, urticaria, Stevens-Johnson syndrome, erythema multiforme, blurred vision, tinnitus, gynecomastia, galactorrhea/hyperprolactinemia, increased urination, spotty menstruation, impotence, flushing, abdominal discomfort

I.V.: <1% (Limited to important or life-threatening): Bronchi/laryngeal spasm, itching, urticaria, emotional depression, rotary nystagmus, sleepiness, vertigo, muscle fatigue, diaphoresis, respiratory failure, myoclonus

Postmarketing and/or case reports: Stevens-Johnson syndrome, erythema multiforme, exfoliative dermatitis, EPS, gynecomastia, eosinophilia, ventricular fibrillation, asystole, electrical mechanical dissociation, shock, myoclonus, Parkinsonian syndrome, GI obstruction, pulmonary edema, respiratory failure, hair color change


Overdosage/Toxicology

 Primary cardiac symptoms of calcium blocker overdose include hypotension and bradycardia (second- or third-degree atrioventricular block, or sinus arrest with junctional rhythm). Intraventricular conduction is usually not affected so QRS duration is normal (verapamil does prolong the PR interval).

Noncardiac symptoms include confusion, stupor, nausea, vomiting, metabolic acidosis and hyperglycemia. Following initial gastric decontamination, if possible, repeated calcium administration may promptly reverse depressed cardiac contractility (but not sinus node depression or peripheral vasodilation). Large doses of calcium chloride (up to 1 g/hour for 24 hours) have been used in refractory cases. Glucagon, epinephrine, and amrinone may treat refractory hypotension. Glucagon and epinephrine also increase heart rate (outside the U.S., 4-aminopyridine may be available as an antidote). Dialysis and hemoperfusion are not effective in enhancing elimination although repeat-dose activated charcoal may serve as an adjunct with sustained-release preparations.


Drug Interactions

 Substrate of CYP1A2 (minor), 2B6 (minor), 2C8/9 (minor), 2C18 (minor), 2E1 (minor), 3A4 (major); Inhibits CYP1A2 (weak), 2C8/9 (weak), 2D6 (weak), 3A4 (moderate)

Alfentanil's plasma concentration is increased. Fentanyl and sufentanil may be affected similarly.

Amiodarone use may lead to bradycardia and decreased cardiac output. Monitor closely if using together.

Aspirin and concurrent verapamil use may increase bleeding times; monitor closely, especially if on other antiplatelet agents or anticoagulants.

Azole antifungals may inhibit the calcium channel blocker's metabolism; avoid this combination. Try an antifungal like terbinafine (if appropriate) or monitor closely for altered effect of the calcium channel blocker.

Barbiturates reduce the plasma concentration of verapamil. May require much higher dose of verapamil.

Beta-blockers may have increased pharmacodynamic interactions with verapamil (see Warnings/Precautions).

Buspirone's serum concentration may increase. May require dosage adjustment.

Calcium may reduce the calcium channel blocker's effects, particularly hypotension.

Carbamazepine's serum concentration is increased and toxicity may result; avoid this combination.

Cimetidine reduced verapamil's metabolism; consider an alternative H2 antagonist.

Cyclosporine's serum concentrations are increased by verapamil; avoid this combination. Use another calcium channel blocker or monitor cyclosporine trough levels and renal function closely.

CYP3A4 inducers: CYP3A4 inducers may decrease the levels/effects of verapamil. Example inducers include aminoglutethimide, carbamazepine, nafcillin, nevirapine, phenobarbital, phenytoin, and rifamycins.

CYP3A4 inhibitors: May increase the levels/effects of verapamil. Example inhibitors include azole antifungals, ciprofloxacin, clarithromycin, diclofenac, doxycycline, erythromycin, imatinib, isoniazid, nefazodone, nicardipine, propofol, protease inhibitors, and quinidine.

CYP3A4 substrates: Verapamil may increase the levels/effects of CYP3A4 substrates. Example substrates include benzodiazepines, calcium channel blockers, cyclosporine, mirtazapine, nateglinide, nefazodone, sildenafil (and other PDE-5 inhibitors), tacrolimus, and venlafaxine. Selected benzodiazepines (midazolam and triazolam), cisapride, ergot alkaloids, selected HMG-CoA reductase inhibitors (lovastatin and simvastatin), and pimozide are generally contraindicated with strong CYP3A4 inhibitors.

Digoxin's serum concentration is increased; reduce digoxin's dose when adding verapamil.

Doxorubicin's clearance was reduced; monitor for altered doxorubicin's effect.

Erythromycin may increase verapamil's effects; monitor altered verapamil effect.

Ethanol's effects may be increased by verapamil; reduce ethanol consumption.

Flecainide may have additive negative effects on conduction and inotropy.

Grapefruit juice: Verapamil serum concentrations may be increased by grapefruit juice. Avoid concurrent use.

HMG-CoA reductase inhibitors (atorvastatin, cerivastatin, lovastatin, simvastatin): Serum concentration will likely be increased; consider pravastatin/fluvastatin or a dihydropyridine calcium channel blocker. If concurrent use with lovastatin is unavoidable, dose of lovastatin should not exceed 40 mg/day.

Lithium neurotoxicity may result when verapamil is added; monitor lithium levels.

Midazolam's plasma concentration is increased by verapamil; monitor for prolonged CNS depression.

Nafcillin decreases plasma concentration of verapamil; avoid this combination.

Nondepolarizing muscle relaxant: Neuromuscular blockade may be prolonged. Monitor closely.

Prazosin's serum concentration increases; monitor blood pressure.

Quinidine's serum concentration is increased; adjust quinidine's dose as necessary.

Rifampin increases the metabolism of calcium channel blockers; adjust the dose of the calcium channel blocker to maintain efficacy.

Sildenafil, tadalafil, vardenafil: Blood pressure-lowering effects may be additive; use caution.

Tacrolimus's serum concentrations are increased by verapamil; avoid the combination. Use another calcium channel blocker or monitor tacrolimus trough levels and renal function closely.

Theophylline's serum concentration may be increased by verapamil. Those at increased risk include children and cigarette smokers.


Ethanol/Nutrition/Herb Interactions

Ethanol: Avoid or limit ethanol (may increase ethanol levels).

Food: Grapefruit juice may increase the serum concentration of verapamil; avoid concurrent use.

Herb/Nutraceutical: St John's wort may decrease levels. Avoid dong quai if using for hypertension (has estrogenic activity). Avoid ephedra, yohimbe, ginseng (may worsen arrhythmia or hypertension). Avoid garlic (may have increased antihypertensive effect).


Stability

 Store injection at room temperature; protect from heat and from freezing; use only clear solutions; compatible in solutions of pH of 3-6, but may precipitate in solutions having a pH 6


Compatibility

 Stable in dextran 40 10% in NS, dextran 75 6% in NS, D5LR, D5 1 /2NS, D5NS, D5W, LR, 1 /2NS, NS

Y-site administration: Compatible: Ciprofloxacin, clarithromycin, dobutamine, dopamine, famotidine, gatifloxacin, hydralazine, inamrinone, linezolid, meperidine, milrinone, penicillin G potassium, piperacillin, ticarcillin. Incompatible: Albumin, amphotericin B cholesteryl sulfate complex, ampicillin, nafcillin, oxacillin, propofol, sodium bicarbonate

Compatibility in syringe: Compatible: Heparin, inamrinone, milrinone

Compatibility when admixed: Compatible: Amikacin, amiodarone, ascorbic acid, atropine, bretylium, calcium chloride, calcium gluconate, cefamandole, cefazolin, cefotaxime, cefoxitin, chloramphenicol, cimetidine, clindamycin, dexamethasone sodium phosphate, diazepam, digoxin, dopamine, epinephrine, erythromycin lactobionate, gentamicin, heparin, hydrocortisone sodium phosphate, hydrocortisone sodium succinate, hydromorphone, insulin (regular), isoproterenol, lidocaine, magnesium sulfate, mannitol, meperidine, metaraminol, methyldopate, methylprednisolone sodium succinate, metoclopramide, morphine, multivitamins, naloxone, nitroglycerin, norepinephrine, oxytocin, pancuronium, penicillin G potassium, penicillin G sodium, pentobarbital, phenobarbital, phentolamine, phenytoin, piperacillin, potassium chloride, potassium phosphates, procainamide, propranolol, protamine, quinidine gluconate, sodium bicarbonate, sodium nitroprusside, theophylline, ticarcillin, tobramycin, tolazoline, vancomycin, vasopressin, vitamin B complex with C. Incompatible: Albumin, amphotericin B, floxacillin, hydralazine, trimethoprim/sulfamethoxazole. Variable (consult detailed reference): Aminophylline, ampicillin, dobutamine, furosemide, nafcillin, oxacillin


Mechanism of Action

 Inhibits calcium ion from entering the "slow channels" or select voltage-sensitive areas of vascular smooth muscle and myocardium during depolarization; produces a relaxation of coronary vascular smooth muscle and coronary vasodilation; increases myocardial oxygen delivery in patients with vasospastic angina; slows automaticity and conduction of AV node.


Pharmacodynamics/Kinetics

Onset of action: Peak effect: Oral: Immediate release: 2 hours; I.V.: 1-5 minutes

Duration: Oral: Immediate release tablets: 6-8 hours; I.V.: 10-20 minutes

Protein binding: 90%

Metabolism: Hepatic via multiple CYP isoenzymes; extensive first-pass effect

Bioavailability: Oral: 20% to 30%

Half-life elimination: Infants: 4.4-6.9 hours; Adults: Single dose: 2-8 hours, Multiple doses: Up to 12 hours; prolonged with hepatic cirrhosis

Excretion: Urine (70%, 3% to 4% as unchanged drug); feces (16%)


Dosage

Children: SVT:

I.V.:

<1 year: 0.1-0.2 mg/kg over 2 minutes; repeat every 30 minutes as needed

1-15 years: 0.1-0.3 mg/kg over 2 minutes; maximum: 5 mg/dose, may repeat dose in 15 minutes if adequate response not achieved; maximum for second dose: 10 mg/dose

Oral (dose not well established):

1-5 years: 4-8 mg/kg/day in 3 divided doses or 40-80 mg every 8 hours

>5 years: 80 mg every 6-8 hours

Adults:

SVT: I.V.: 2.5-5 mg (over 2 minutes); second dose of 5-10 mg (~0.15 mg/kg) may be given 15-30 minutes after the initial dose if patient tolerates, but does not respond to initial dose; maximum total dose: 20 mg

Angina: Oral: Initial dose: 80-120 mg 3 times/day (elderly or small stature: 40 mg 3 times/day); range: 240-480 mg/day in 3-4 divided doses

Hypertension: Oral:

Immediate release: 80 mg 3 times/day; usual dose range (JNC 7): 80-320 mg/day in 2 divided doses

Sustained release: 240 mg/day; usual dose range (JNC 7): 120-360 mg/day in 1-2 divided doses; 120 mg/day in the elderly or small patients (no evidence of additional benefit in doses >360 mg/day).

Extended release:

Covera-HS®: Usual dose range (JNC 7): 120-360 mg once daily (once-daily dosing is recommended at bedtime)

Verelan® PM: Usual dose range: 200-400 mg once daily at bedtime

Dosing adjustment in renal impairment: Clcr<10 mL/minute: Administer at 50% to 75% of normal dose.

Dialysis: Not dialyzable (0% to 5%) via hemo- or peritoneal dialysis; supplemental dose is not necessary.

Dosing adjustment/comments in hepatic disease: Reduce dose in cirrhosis, reduce dose to 20% to 50% of normal and monitor ECG.


Administration

Oral: Do not crush or chew sustained or extended release products.

Calan® SR, Isoptin® SR: Administer with food.

Verelan®, Verelan® PM: Capsules may be opened and the contents sprinkled on 1 tablespoonful of applesauce, then swallowed without chewing.

I.V.: Rate of infusion: Over 2 minutes.


Monitoring Parameters

 Monitor blood pressure closely


Reference Range

 Therapeutic: 50-200 ng/mL (SI: 100-410 nmol/L) for parent; under normal conditions norverapamil concentration is the same as parent drug. Toxic: >90 mcg/mL


Dietary Considerations

 Calan® SR and Isoptin® SR products may be taken with food or milk, other formulations may be administered without regard to meals; sprinkling contents of Verelan® or Verelan® PM capsule onto applesauce does not affect oral absorption.


Patient Education

 Oral: Take as directed. Do not alter dosage or discontinue therapy without consulting prescriber. Do not crush or chew sustained or extended release forms. Avoid grapefruit juice; avoid (or limit) alcohol and caffeine. You may experience dizziness or lightheadedness (use caution when driving or engaging in tasks requiring alertness until response to drug is known); nausea or vomiting (small, frequent meals, frequent mouth care, chewing gum, or sucking lozenges may help); constipation (increased exercise, fluids, fruit, or fiber may help); or diarrhea (buttermilk, boiled milk, or yogurt may help). Report chest pain, palpitations, or irregular heartbeat; unusual cough, respiratory difficulty, or swelling of extremities (feet/ankles); muscle tremors or weakness; confusion or acute lethargy; or skin irritation or rash. Pregnancy precaution: Inform prescriber if you are or intend to become pregnant.


Anesthesia and Critical Care Concerns/Other Considerations

 I.V. administration, hypertrophic cardiomyopathy, sick sinus syndrome, moderate to severe congestive heart failure, concomitant therapy with beta-blockers or digoxin can all increase incidence of adverse effects. Verapamil should be avoided in patients with left ventricular dysfunction, pulmonary congestion, or heart failure. Verapamil may be administered intravenously in the acute setting to attain ventricular rate control in patients with atrial fibrillation or flutter. Patients that respond, defined in general as at least a 20% decrease in ventricular response rate or attaining a rate <100 beats/minute, can be continued on oral therapy to maintain control. It is important to consider the potential drug interaction with digoxin, as these agents are both used in this setting.


Cardiovascular Considerations

 Verapamil is an effective antihypertensive alone or in combination with other agents. Therapy should be individualized with consideration given to the patient's concomitant diseases and compelling indications for therapy. A verapamil preparation (Covera® HS, Verelan® PM) uses a chronotherapeutic approach to the treatment of hypertension and angina. This drug preparation provides peak drug effects in the early morning when the circadian distribution of cardiovascular events is also at a peak. The benefit of this theoretical approach to treatment has not been established. The CONVINCE trial is currently underway to address this issue.

There is some evidence that verapamil may reduce mortality in nonfatal cardiac events, primarily myocardial infarction, in patients with history of myocardial infarction (DAVIT-II). It is important to note that this benefit was observed in patients with coronary artery disease without heart failure.

In the treatment of acute myocardial infarction, verapamil may be used to treat hypertension or ongoing ischemia if beta-blocker therapy is ineffective or contraindicated and in the absence of left ventricular dysfunction, pulmonary congestion or AV block. In this setting, verapamil may be beneficial. Verapamil should be avoided in patients with left ventricular dysfunction or pulmonary congestion.

Verapamil may be administered intravenously in the acute setting to attain ventricular rate control in patients with atrial fibrillation or flutter. Patients that respond, defined in general as at least a 20% decrease in ventricular response rate or attaining a rate <100 beats/minute, can be continued on oral therapy to maintain control. It is important to consider the potential drug interaction with digoxin, as these agents are both used in this setting.

In the treatment of unstable angina/non-ST-segment elevation MI, a nondihydropyridine calcium antagonist (diltiazem or verapamil) may be considered in patients with continuing or frequently recurring ischemia when beta-blockers are contraindicated (Class I). Oral long-acting calcium antagonists may also be considered in addition to beta-blockers and nitrates (Class IIa).


Dental Health: Effects on Dental Treatment

 Key adverse event(s) related to dental treatment: Gingival hyperplasia. Calcium channel blockers (CCB) have been reported to cause gingival hyperplasia (GH). Verapamil induced GH has appeared 11 months or more after subjects took daily doses of 240-360 mg. The severity of hyperplastic syndrome does not seem to be dose-dependent. Gingivectomy is only successful if CCB therapy is discontinued. GH regresses markedly 1 week after CCB discontinuance with all symptoms resolving in 2 months. If a patient must continue CCB therapy, begin a program of professional cleaning and patient plaque control to minimize severity and growth rate of gingival tissue.


Dental Health: Vasoconstrictor/Local Anesthetic Precautions

 No information available to require special precautions


Mental Health: Effects on Mental Status

 May cause drowsiness, dizziness, confusion, insomnia, psychotic symptoms, and extrapyramidal symptoms


Mental Health: Effects on Psychiatric Treatment

 Barbiturates may decrease verapamil serum concentrations; verapamil may increase buspirone, carbamazepine, and midazolam serum concentrations; concurrent use with lithium may cause an increase or decrease in serum lithium concentrations; monitor; verapamil has been used to treat bipolar disorder, mania


Dosage Forms

Caplet, sustained release (Calan® SR): 120 mg, 180 mg, 240 mg

Capsule, extended release: 120 mg, 180 mg, 240 mg

Verelan® PM: 100 mg, 200 mg, 300 mg

Capsule, sustained release, as hydrochloride (Verelan®): 120 mg, 180 mg, 240 mg, 360 mg

Injection, solution, as hydrochloride: 2.5 mg/mL (2 mL, 4 mL)

Tablet, as hydrochloride (Calan®): 40 mg, 80 mg, 120 mg

Tablet, extended release: 120 mg, 180 mg, 240 mg

Covera HS®: 180 mg, 240 mg

Tablet, sustained release, as hydrochloride (Isoptin® SR): 120 mg, 180 mg, 240 mg


Extemporaneously Prepared

 A 50 mg/mL oral suspension may be made using twenty 80 mg verapamil tablets, 3 mL of purified water USP, 8 mL of methylcellulose 1% and simple syrup qs ad to 32 mL; the expected stability is 30 days under refrigeration; shake well before use. A mixture of verapamil 50 mg/mL plus hydrochlorothiazide 5 mg/mL was stable 60 days in refrigerator in a 1:1 preparation of Ora-Sweet® and Ora-Plus®, of Ora-Sweet® SF and Ora-Plus®, and of cherry syrup.

Allen LV and Erickson III MA, "Stability of Labetalol Hydrochloride, Metoprolol Tartrate, Verapamil Hydrochloride, and Spironolactone With Hydrochlorothiazide in Extemporaneously Compounded Oral Liquids," Am J Health Syst Pharm , 1996, 53:304-9.

Nahata MC and Hipple TF, Pediatric Drug Formulations , 2nd ed, Cincinnati, OH: Harvey Whitney Books Co, 1992.


References

Antman EM, Anbe SC, Alpert JS, et al, "ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction - Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)," Circulation, 2004, 110:588-636. Available at: http://www.circulationaha.org/cgi/content/full/110/5/588. Last accessed October 26, 2004.

Braunwald E, Antman EM, Beasley JW, et al, "ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction - Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina)," J Am Coll Cardiol , 2002, 40(7):1366-74. Available at: http://www.acc.org/clinical/guidelines/unstable/incorporated/index.htm. Accessed May 20, 2003.6;9R

Chobanian AV, Bakris GL, Black HR, et al, "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report," JAMA , 2003, 289(19):2560-71.

"Effect of Verapamil on Mortality and Major Events After Acute Myocardial Infarction. The Danish Verapamil Infarction Trial II-DAVIT II," Am J Cardiol , 1990, 66(10):779-85.

Rengo F, Carbonin P, Pahor M, et al, "A Controlled Trial of Verapamil in Patients After Acute Myocardial Infarction: Results of the Calcium Antagonist Reinfarction Italian Study," Am J Cardiol , 1996, 77(5):365-9.

"Verapamil in Acute Myocardial Infarction. Danish Multicenter Study Group on Verapamil in Myocardial Infarction," Am J Cardiol , 1984, 54(11):24E-28E.


International Brand Names

 Akilen® (HK); Alti-Verapamil (CA); Angimil® (BD); Anpec® (AU); Apoacor® (IL); Apo-Verap® (CA, PL); Azupamil® [caps] (CZ); Azupamil® (DE); Berkatens® (CZ, IE); Calan® (CA); Calaptin® (IN); Calcicard® (ZA); Cardinorm® (IT); Cardiolen® (CL); Cardioprotect® (DE); Cardiover® (ID); Caveril® (CY, JO, TH); Chinopamil R® (HU); Chronovera® (CA); Civicor® (HK, NZ); Cloridrato de Verapamil® (BR); Coragina® (DO); Cordamil® (RO); Cordilox® (AU, GB); Cordimil® (DE); Corpamil® (ID); Covera® (CA); Cronovera® (BR, MX); Devincil® (LU); Dilacoran® (MX); Dilacoron® (BR); durasoptin® (DE); Ethimil® (GB); Falicard® (DE, RO); Fibrocard® (BE, LU, TR); Finoptin® (RU); Flamon® (CH); Geangin® (DK, NL); Gen-Verapamil (CA); Gen-Verapamil SR (CA); Half Securon® (DE); Half Securon SR® (GB); Hexasoptin® (DK); Ikacor® (IL); Ikapress® (IL); Isopamil® (TH); Isoptina® (CL); Isoptin® (AT, AU, BE, CA, CH, CO, CZ, DE, DK, EG, FI, HR, HU, IE, IT, JO, KW, LB, LU, NL, NO, NZ, PL, PT, RO, RU, SE, SG, SI, TH, TR, ZA); Isoptine® (BE, FR); Isoptin® I.V. (CA); Isoptino® (AR); Isoptin® Retard (AT, CH, FI, NO, SE); Isoptin® RR retard (AT); Isoptin® SR (CA); Isoptin SR® (CR, DO, GT, HN, HU, ID, IE, PA, SV, TH, ZA); Izopamil® (YU); Jenapamil® (DE); Lekoptin® (CZ, PL, RU, SI); Librapamil® (EC); Lodixal® (BE); Manidon® (ES); Niposoluted® (EC); Novo-Veramil (CA, PL); Novo-Veramil SR (CA); Nu-Verap (CA); Ormil® (TR); Presocor® (CL); Q-Med Verapamil Injection® (ZA); Quasar® (IT); Quiduna® (DE); Ranil® (RO); Ravamil SR® (ZA); Redupres® (ES); Rolab-Verapamil HCl® (ZA); Securon® (GB); Securon SR® (GB); Staveran® (PL); Tarka® (GB, SE); Univer® (GB); Vasodil-40® (BD); Vasomil® (ZA); Vepamil® (YU); Vera 1A Pharma® (DE); Vera AbZ® (DE); Verabeta® (DE); Veracaps SR® (AU); Veracard® (RU); Veracor® (IL); Veragamma® (DE); Vera Heumann® (DE); Verahexal® (AU, CZ, DE, LU, RO, ZA); Verakard® (NO); Veral® (AR); Vera Lich® (DE); Veraloc® (DK); Veramex® (DE); Veramil® (IE, IN); Veranorm® (DE); Verapabene® (AT); Verapal® (AR); Verapam® (CH); Verapamil 1A Farma® (DK); Verapamil 1A-Pharma® (DE); Verapamil acis® (DE); Verapamil AL® (CZ, DE, HU); Verapamil Atid® (DE); Verapamil Basics® (DE); Verapamil® (BG, BR, CZ, GB, HR, HU, IE, PL, RO, RU, YU); Verapamil-Cophar® (CH); Verapamil DOC® (IT); Verapamil Hennig® (DE); Verapamil Hexan® (IT); Verapamil Hydrochloride® (RU); Verapamil Lindo® (DE); Verapamil Merck® (IT); Verapamil NM® (DK); Verapamil NM Pharma® (SE); Verapamilo Clorhidrato® (CL); Verapamilo® (CO, EC); Verapamilo Genfar® (EC); Verapamilo MK® (CO, CR, DO, GT, HN, PA, SV); Verapamil PB® (DE); Verapamil Pharmavit® (HU); Verapamil Ratio® (DO); Verapamil Ratiopharm® (DE, IT, RU); Verapamil Sandoz® (DE); Verapamil-Teva® (DE); Verapamil Teva® (IT); Verapamil Verla® (DE); Verapamil Wolff® (DE); Verap® (IE); Verapin® (TH); Verapress MR® (GB); Verasal® (DE); Verastad® (AT); Veratad® (CO); Veratensin® (ES); vera von ct® (DE); Verelan® (IE); Verisop® (IE); Vermine® (TH); Vermin® (FI); Verogalid ER® (CZ, HU); Veroptinstada® (DE); Veroptin® (TR); Verpamil® (CZ, EG, FI, HK, JO, KW, LB, NZ, RO, SG); Vertab® (GB); Zolvera® (GB)


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