VERAMIL, VERAPAMIL TABLETS 40 MG - summary of medicine characteristics

1 NAME OF THE MEDICINAL PRODUCT

Veramil

Verapamil Tablets 40 mg

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

Verapamil Hydrochloride BP 40 mg

3 PHARMACEUTICAL FORM

Film-coated tablet

4 CLINICAL PARTICULARS

4.1 Therapeutic indications

1. The prophylaxis and treatment of angina pectoris.

2. Prophy laxis and treatment of suprav entricular paroxy smal tachycardia; atr ial fibrillation and premature supraventricular contractions; atrial fibrillation and flutter and s upraventricular pa roxysmal t achycardia of the re ciprocating ty pe, a ssociated with the Wolff-Parkinson-White Syndrome.

3. Treatment either alone or in conjunction with other anti-hypertensive therapy of mild to moderate hypertension (including renal hypertension).

4.2 Posology and method of administration

Angina:

Adults:        120 mg t.d.s. is recommended. 80 mg t.d.s. can be completely

satisfactory in some patients with angina of effort. Less than 120 mg t.d.s. is not likely to be effective in angina at rest and variant angina.

Children:      Not applicable.

Elderly:        As for adults, unless liver or renal function is impaired.

Supraventricular paroxysmal tachycardia:

Adults:         40–120 t.d.s. according to the severity of the condition.

Children:      Up to 2 years: 20 mg 2–3 t.d.s.

2 years and above: 40–120 mg 2–3 t.d.s. according to age and effect.

Elderly:It is recommended to commence with lowest dose and adjust as required.

Hypertension:

Adults: The usual dose range is 80–160 mg t.d.s. The dose should be increased from 80 mg t.d.s. at weekly intervals according to response, either alone or in conjunction with other antihypertensive therapy. A further reduction in blood pressure may be obtained by combining VERAMIL with other antihypertensive agents, e.g. thiazide diuretics.

Children:      Up to 10 mg per kilo bodyweight per day in divided doses,

according to severity of disease.

Elderly:It is recommended to commence with the lowest dose and adjust as required.

Route of administration: Oral

4.3 Contraindications

Sick sinus syndrome, sec ond or t hird deg ree at rioventricular block, cardiogenic shock, acute myocardial infarction complicated by bradycardia, marked hypotension or left ventricular failure, sino-atrial block, history of heart failure, bradycardia of less than 50 beats/minute or hypotension of less than 90mmHg systolic.

Atrial flutter or fibrillation complicating Wolff-Parkinson-White syndrome.

Porphyria.

Concomitant ingestion of grapefruit juice.

4.4 Special warnings and precautions for use

Care should be exercised when beta-blockers are administered either concurrently or closely together because the effects of beta-blockers and VERAMIL may be additive with respect to both contraction and conduction. This is particularly important when either drug is administered intravenously.

VERAMIL should be used with caution in patients with first-degree atrioventricular block because impulse conduction may be affected.

Left ventricular contractility may be affec ted by VERAMIL because of its mode of action; cardiac failure may therefore be precipitated or, if it already exists, may be aggravated by VERAMIL.

It is the refore important tha t VERAMIL should only be adm inistered after appropriate

therapy for cardiac failure has been instituted, e.g. digoxin etc. Patients with impaired liver function exhibit reduced drug metabolism and therefore careful attention should be paid to dosage in these patients.

The disposition of verapamil in patients with renal impairment has not been fully established and therefore careful patient monitoring is recommended. Verapamil is not

removed during dialysis.

VERAMIL should not be used in children with arrhythmias without specialist advice; some supraventricular arrhythmias in childhood can be accelerated by verapamil with dangerous consequences.

Patients starting therapy with simvastatin should be advised of the risk of myopathy and told to report promptly unexplained muscle pain, tenderness or weakness. A CPK level ab ove 10× ULN in a pat ient wi th un explained m uscle sy mptoms indicate s myopathy. Si mvastatin therapy should be di scontinued if m yopathy is diag nosed or suspected. Pe riodic CPK dete rminations m ay be cons idered (see s ection 4. 5 ‘Interactions with other Medicaments and forms of Interaction’).

Patients w ith rare her editary prob lems of g alactose in tolerance, L app lac tase deficiency

or glucose/galactose malabsorbtion should not take Veramil.

4.5 Interaction with other medicinal products and other forms of interaction

VERAMIL incre ases th e serum concen tration o f d igoxin with increased risk AV block and bradycardia; the awareness of the possibility of digitalis toxicity should also be borne in mind.

Verapamil also increases the plasma concentration of imipramine and possibly other tricyclics, ciclosporin, theophylline and drugs under CYP-450 system (e.g. buspirone, dutasteride, eplerenone, atazanavir, ritonavir, sirolimus simvastatin).

There is an increased risk of myopathy when verapamil is given with simvastatin (see section 4.4 ‘Special Warnings and Precautions for Use’).

Verapamil in hibits the m etabolism of midazolam; incre ased p lasma-midazolam increases

sedation.

The effects of carbamazepine and suxamethonium are enhanced by verapamil.

Verapamil enhances the effect of non-depolarising muscle relaxants (e.g. atracurium, pancuronium) possib ly causi ng hy potension, myocardial d epression and hyperkalaemia.

Concomitant use of verapamil and intravenous dantrolene may cause hypotension, myocardial depression and hyperkalaemia.

Grapefruit juice – an increase in verapamil serum level has been reported.

The e ffects o f v erapamil m ay be addi tive to other d rugs whi ch c an produce a hypotensive

effect. Examples of these are alcohol, aldesleukin, alprostadil, and anaesthetics with risk of AV del ay, anti hypertensives, diu retics, ant ipsychotics, anxio lytics & hypnotics, bac lofen, isoflurane, lev odopa, MAOIs, nit rates, n itroprusside an d tizanidine.

Hypotensive effect of calcium-channel blockers e.g. verapamil is antagonised with

concomitant use of NSAIDs, corticosteroids or oestrogens.

Concomitant use of be ta-blockers and v erapamil may cause s evere hypotension and even

heart fa ilure and sho uld only be g iven tog ether if myocardial fun ction i s wel l preserved.

Enhanced hy potensive effe ct has be en reported when calc ium channel bl ockers are given

with al pha-blockers. There is also an increased risk of fi rst-dose hy potension with postsynaptic alpha-blockers such as prazosin.

Cimetidine may inhibit metabolism of verapamil causing increased verapamil-plasma concentrations.

Amiodarone-induced risk of brady cardia, AV blo ck and m yocardial depr ession is increased by verapamil.

There is poss ibly increa sed risk of brady cardia when calc ium-channel bl ockers are given with mefloquine.

Concomitant use of verapamil with disopyramide and flecainide increases risk of

myocardial depression and asystole.

Verapamil may raise the plasma concentration of quinidine resulting in extreme hypotension.

Rifampicin increases the metabolism of verapamil thereby significantly reducing its plasma concentration.

The effect of verapamil is also reduced by phenobarbitol, primidone and phenytoin.

Neurotoxicity may occur without increased plasma-lithium concentrations in patients given verapamil.

4.6 Pregnancy and lactation

Verapamil is not recommended for use during pregnancy unless the benefits of the drug outweigh the possible hazards to the foetus.

4.7 Effects on ability to drive and use machines

Depending on individual susceptibility, the patient’s ability to drive a vehicle or operate machinery may be impaired, particularly in the initial stages of treatment, or when changing over from another drug. Verapamil has been shown to increase the blood levels of alcohol and slow its elimination. Therefore, the effects of alcohol may be exaggerated.

4.8 Undesirable effects

Administration of Verapamil is commonly associated with constipation. Occasionally the fo llowing side- effects may be experi enced: N ausea a nd v omiting, flus hing, headache, d izziness, fatigue ank le oe dema, m yalgia, ar thralgia, p araesthesia, an d erythromelalgia; increased prolactin concentration. On rare occasions gynaecomastia and g ingival hy perplasia may occur aft er lo ng-term trea tment, aft er i ntravenous administration of high doses, hypotension, heart failure, bradycardia, heart block, and asystole.

Sensitivity o r all ergy t o Verapamil i s ra re. S ymptoms o f a llergy a re er ythema, pruritis, urticaria, angioedema and Stevens-Johnson syndrome.

4.9 Overdose

The c lassical m easures for cardiovascular s ide effects sh ould be instituted immediately. C ardiac arrest sh ould be treated b y heart m assage, m echanical respiration and the ne cessary int ensive are appropriate to the c ondition sh ould be instituted.

In the ca se o f hypotension, dop amine, no radrenalin or dobu tamine m ay be used together wi th appropriate posi tioning of the p atient. L ikewise, in m yocardial insufficiency treatment should be either dopamine, dobutamine, cardiac glucosides or 10–20 ml of a 10% solu tion of calcium gluconate. Second or t hird degree AV block should be treated with atropine or isoprenaline and if necessary a pace maker should be used.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Verapamil is a Class 4 anti-arrhythmic agent which acts on supraventricular arrhythmias through interfering with calcium conductants.

5.2 Pharmacokinetic properties

Verapamil is almost completely absorbed from the gastro-intestinal tract but is subject to very considerable first-pass metabolism in the liver. The plasma half-life is about 7 hours following oral administration and that of its active metabolite which is norverapamil is about nine hours.

Verapamil acts within minutes of intravenous administration but its effects may only last for about half-an-hour. It may require two hours to act after oral administration with peak effect after five hours.

Verapamil is extensively bound to plasma proteins. The drug is mainly excreted by the kidneys in the form of its metabolites, but some is also excreted in the bile and in the faeces.

5.3 Preclinical safety data

Not applicable.

6 PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Maize Starch

Lactose

Gelatin

Colloidal Anhydrous Silica

Talc

Magnesium Stearate

Opaspray K-IF-3048

Hydroxypropyl­methylcellulo­se 2190

Ethylcellulose

Diethylphthalate

6.2 Incompatibilities

None known.

6.3 Shelf life

24 months.

6.4 Special precautions for storage

Store below 25 deg C in a dry place in well closed containers.

6.5 Nature and contents of container

High density polystyrene with polythene lids and/or polypropylene containers with polypropylene or polythene lids and polyurethane/po­lythene inserts.

Pack sizes: 100 and 500