|Pharmacotherapeutic group Chemical name Description Clinical Pharmacology Indications ContraIndications Warnings Precautions Side effects Dosage and administration Overdosage Drug interactions Patient Information How Supplied Storage conditions And Handling|
CALAN SR (verapamil hydrochloride) is a calcium ion
influx inhibitor (slow-channel blocker or calcium ion antagonist).CALAN SR is available
for oral administration as light green, capsule-shaped, scored, film-coated
tablets (caplets) containing 240 mg of verapamil hydrochloride;as light pink,
oval, scored, film-coated tablets (caplets) containing 180 mg of verapamil
hydrochloride;and as light violet, oval, film-coated tablets (caplets)
containing 120 mg of verapamil hydrochloride.The caplets are designed for
sustained release of the drug in the gastrointestinal tract;sustained-release
characteristics are not altered when the caplet is divided in half.The
structural formula of verapamil HCl is:
CALAN (verapamil HCl) is a calcium ion influx inhibitor (slow-channel blocker or calcium ion antagonist) that exerts its pharmacologic effects by modulating the influx of ionic calcium across the cell membrane of the arterial smooth muscle as well as in conductile and contractile myocardial cells.
Verapamil exerts antihypertensive effects by decreasing
systemic vascular resistance, usually without orthostatic decreases in blood
pressure or reflex tachycardia;bradycardia (rate less than 50 beats/min) is
uncommon (1.4%).During isometric or dynamic exercise, CALAN does not alter
systolic cardiac function in patients with normal ventricular function.
CALAN does not alter total serum calcium levels.However, one report suggested that calcium levels above the normal range may alter the therapeutic effect of CALAN.
CALAN dilates the main coronary arteries and coronary
arterioles, both in normal and ischemic regions, and is a potent inhibitor of
coronary artery spasm, whether spontaneous or ergonovineinduced.This property
increases myocardial oxygen delivery in patients with coronary artery spasm and
is responsible for the effectiveness of CALAN in vasospastic (Prinzmetal"s or
variant) as well as unstable angina at rest.Whether this effect plays any role
in classical effort angina is not clear, but studies of exercise tolerance have
not shown an increase in the maximum exercise rate-pressure product, a widely
accepted measure of oxygen utilization.This suggests that, in general, relief
of spasm or dilation of coronary arteries is not an important factor in
CALAN regularly reduces the total systemic resistance (afterload) against which the heart works both at rest and at a given level of exercise by dilating peripheral arterioles.
Electrical activity through the AV node depends, to a significant degree, upon calcium influx through the slow channel.By decreasing the influx of calcium, CALAN prolongs the effective refractory period within the AV node and slows AV conduction in a raterelated manner.
Normal sinus rhythm is usually not affected, but in patients with sick sinus syndrome, CALAN may interfere with sinus-node impulse generation and may induce sinus arrest or sinoatrial block.Atrioventricular block can occur in patients without preexisting conduction defects (see WARNINGS).
CALAN does not alter the normal atrial action potential or intraventricular conduction time, but depresses amplitude, velocity of depolarization, and conduction in depressed atrial fibers.CALAN may shorten the antegrade effective refractory period of the accessory bypass tract. Acceleration of ventricular rate and/or ventricular fibrillation has been reported in patients with atrial flutter or atrial fibrillation and a coexisting accessory AV pathway following administration of verapamil (see WARNINGS).
CALAN has a local anesthetic action that is 1.6 times that of procaine on an equimolar basis.It is not known whether this action is important at the doses used in man.
CALAN reduces afterload and myocardial contractility. Improved left ventricular diastolic function in patients with Idiopathic Hypertrophic Subaortic Stenosis (IHSS) and those with coronary heart disease has also been observed with CALAN.In most patients, including those with organic cardiac disease, the negative inotropic action of CALAN is countered by reduction of afterload, and cardiac index is usually not reduced.However, in patients with severe left ventricular dysfunction (eg, pulmonary wedge pressure above 20 mm Hg or ejection fraction less than 30%), or in patients taking beta-adrenergic blocking agents or other cardiodepressant drugs, deterioration of ventricular function may occur (see PRECAUTIONS: DRUG INTERACTIONS).
CALAN does not induce bronchoconstriction and, hence, does not impair ventilatory function.
In chronic animal toxicology studies, verapamil caused lenticular and/or suture line changes at 30 mg/kg/day or greater, and frank cataracts at 62.5 mg/kg/day or greater in the beagle dog but not in the rat. Development of cataracts due to verapamil has not been reported in man.
CALAN SR is indicated for the treatment of hypertension,
to lower blood pressure.Lowering blood pressure reduces the risk of fatal and
nonfatal cardiovascular events, primarily strokes and myocardial infarctions.
These benefits have been seen in controlled trials of antihypertensive drugs
from a wide variety of pharmacologic classes including this drug.
Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake.Many patients will require more than one drug to achieve blood pressure goals.For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program"s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC).
Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits.The largest and most consistent cardiovascular outcome benefit has been a reduction in the risk of stroke, but reductions in myocardial infarction and cardiovascular mortality also have been seen regularly.
Elevated systolic or diastolic pressure causes increased cardiovascular risk, and the absolute risk increase per mmHg is greater at higher blood pressures, so that even modest reductions of severe hypertension can provide substantial benefit.Relative risk reduction from blood pressure reduction is similar across populations with varying absolute risk, so the absolute benefit is greater in patients who are at higher risk independent of their hypertension (for example, patients with diabetes or hyperlipidemia), and such patients would be expected to benefit from more aggressive treatment to a lower blood pressure goal.
Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in black patients, and many antihypertensive drugs have additional approved indications and effects (e.g., on angina, heart failure, or diabetic kidney disease).These considerations may guide selection of therapy.
Verapamil HCl caplets are contraindicated in:
Verapamil has a negative inotropic effect, which in most patients is compensated by its afterload reduction (decreased systemic vascular resistance) properties without a net impairment of ventricular performance.In clinical experience with 4,954 patients, 87 (1.8%) developed congestive heart failure or pulmonary edema.Verapamil should be avoided in patients with severe left ventricular dysfunction (eg, ejection fraction less than 30%) or moderate to severe symptoms of cardiac failure and in patients with any degree of ventricular dysfunction if they are receiving a betaadrenergic blocker (see PRECAUTIONS: DRUG INTERACTIONS).Patients with milder ventricular dysfunction should, if possible, be controlled with optimum doses of digitalis and/or diuretics before verapamil treatment.(Note interactions with digoxin under PRECAUTIONS)
Occasionally, the pharmacologic action of verapamil may produce a decrease in blood pressure below normal levels, which may result in dizziness or symptomatic hypotension.The incidence of hypotension observed in 4,954 patients enrolled in clinical trials was 2.5%.In hypertensive patients, decreases in blood pressure below normal are unusual.Tilt-table testing (60 degrees) was not able to induce orthostatic hypotension.
Elevations of transaminases with and without concomitant elevations in alkaline phosphatase and bilirubin have been reported.Such elevations have sometimes been transient and may disappear even in the face of continued verapamil treatment. Several cases of hepatocellular injury related to verapamil have been proven by rechallenge;half of these had clinical symptoms (malaise, fever, and/or right upper quadrant pain) in addition to elevation of SGOT, SGPT, and alkaline phosphatase.Periodic monitoring of liver function in patients receiving verapamil is therefore prudent.
Some patients with paroxysmal and/or chronic atrial fibrillation or atrial flutter and a coexisting accessory AV pathway have developed increased antegrade conduction across the accessory pathway bypassing the AV node, producing a very rapid ventricular response or ventricular fibrillation after receiving intravenous verapamil (or digitalis).Although a risk of this occurring with oral verapamil has not been established, such patients receiving oral verapamil may be at risk and its use in these patients is contraindicated (see CONTRAINDICATIONS).Treatment is usually DC-cardioversion.Cardioversion has been used safely and effectively after oral CALAN.
The effect of verapamil on AV conduction and the SA node may cause asymptomatic first-degree AV block and transient bradycardia, sometimes accompanied by nodal escape rhythms.PR-interval prolongation is correlated with verapamil plasma concentrations, especially during the early titration phase of therapy.Higher degrees of AV block, however, were infrequently (0.8%) observed.Marked firstdegree block or progressive development to second- or third-degree AV block, requires a reduction in dosage or, in rare instances, discontinuation of verapamil HCl and institution of appropriate therapy, depending upon the clinical situation.
In 120 patients with hypertrophic cardiomyopathy (most of them refractory or intolerant to propranolol) who received therapy with verapamil at doses up to 720 mg/day, a variety of serious adverse effects were seen.Three patients died in pulmonary edema;all had severe left ventricular outflow obstruction and a past history of left ventricular dysfunction.Eight other patients had pulmonary edema and/or severe hypotension;abnormally high (greater than 20 mm Hg) pulmonary wedge pressure and a marked left ventricular outflow obstruction were present in most of these patients.Concomitant administration of quinidine (see PRECAUTIONS: DRUG INTERACTIONS) preceded the severe hypotension in 3 of the 8 patients (2 of whom developed pulmonary edema).Sinus bradycardia occurred in 11% of the patients, second-degree AV block in 4%, and sinus arrest in 2%.It must be appreciated that this group of patients had a serious disease with a high mortality rate.Most adverse effects responded well to dose reduction, and only rarely did verapamil use have to be discontinued.
Since verapamil is highly metabolized by the liver, it should be administered cautiously to patients with impaired hepatic function.Severe liver dysfunction prolongs the elimination half-life of immediate-release verapamil to about 14 to 16 hours;hence, approximately 30% of the dose given to patients with normal liver function should be administered to these patients.Careful monitoring for abnormal prolongation of the PR interval or other signs of excessive pharmacologic effects (see OVERDOSAGE) should be carried out.
It has been reported that verapamil decreases neuromuscular transmission in patients with Duchenne"s muscular dystrophy, and that verapamil prolongs recovery from the neuromuscular blocking agent vecuronium.It may be necessary to decrease the dosage of verapamil when it is administered to patients with attenuated neuromuscular transmission.
About 70% of an administered dose of verapamil is excreted as metabolites in the urine.Verapamil is not removed by hemodialysis. Until further data are available, verapamil should be administered cautiously to patients with impaired renal function.These patients should be carefully monitored for abnormal prolongation of the PR interval or other signs of overdosage (see OVERDOSAGE).
An 18-month toxicity study in rats, at a low multiple
(6-fold) of the maximum recommended human dose, and not the maximum tolerated
dose, did not suggest a tumorigenic potential.There was no evidence of a
carcinogenic potential of verapamil administered in the diet of rats for two years
at doses of 10, 35, and 120 mg/kg/day or approximately 1, 3.5, and 12 times, respectively,
the maximum recommended human daily dose (480 mg/day or 9.6 mg/kg/day).
Verapamil was not mutagenic in the Ames test in 5 test strains at 3 mg per plate with or without metabolic activation.
Studies in female rats at daily dietary doses up to 5.5 times (55 mg/kg/day) the maximum recommended human dose did not show impaired fertility.Effects on male fertility have not been determined.
Reproduction studies have been performed in rabbits and rats at oral doses up to 1.5 (15 mg/kg/day) and 6 (60 mg/kg/day) times the human oral daily dose, respectively, and have revealed no evidence of teratogenicity. In the rat, however, this multiple of the human dose was embryocidal and retarded fetal growth and development, probably because of adverse maternal effects reflected in reduced weight gains of the dams.This oral dose has also been shown to cause hypotension in rats.There are no adequate and well-controlled studies in pregnant women.Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.Verapamil crosses the placental barrier and can be detected in umbilical vein blood at delivery.
It is not known whether the use of verapamil during labor or delivery has immediate or delayed adverse effects on the fetus, or whether it prolongs the duration of labor or increases the need for forceps delivery or other obstetric intervention.Such adverse experiences have not been reported in the literature, despite a long history of use of verapamil in Europe in the treatment of cardiac side effects of beta-adrenergic agonist agents used to treat premature labor.
Verapamil is excreted in human milk.Because of the potential for adverse reactions in nursing infants from verapamil, nursing should be discontinued while verapamil is administered.
Safety and efficacy of CALAN SR in pediatric patients below the age of 18 years have not been established.
Serious adverse reactions are uncommon when verapamil
therapy is initiated with upward dose titration within the recommended single
and total daily dose.See WARNINGS for discussion of heart failure,
hypotension, elevated liver enzymes, AV block, and rapid ventricular response.
Reversible (upon discontinuation of verapamil) non-obstructive, paralytic ileus
has been infrequently reported in association with the use of verapamil.The
following reactions to orally administered verapamil occurred at rates greater
than 1.0% or occurred at lower rates but appeared clearly drug-related in
clinical trials in 4,954 patients:
|CHF, Pulmonary edema||1.8%|
|Bradycardia (HR <50/min)||1.4%|
|AV block (total 1° 2° 3°)||1.2%|
|Elevated liver enzymes (see WARNINGS)|
The frequency of cardiovascular adverse reactions that require therapy is rare;hence, experience with their treatment is limited. Whenever severe hypotension or complete AV block occurs following oral administration of verapamil, the appropriate emergency measures should be applied immediately;eg, intravenously administered norepinephrine bitartrate, atropine sulfate, isoproterenol HCl (all in the usual doses), or calcium gluconate (10% solution).In patients with hypertrophic cardiomyopathy (IHSS), alpha-adrenergic agents (phenylephrine HCl, metaraminol bitartrate, or methoxamine HCl) should be used to maintain blood pressure, and isoproterenol and norepinephrine should be avoided.If further support is necessary, dopamine HCl or dobutamine HCl may be administered.Actual treatment and dosage should depend on the severity of the clinical situation and the judgment and experience of the treating physician.
The dose of CALAN SR should be individualized by titration
and the drug should be administered with food.Initiate therapy with 180 mg of sustained-release
verapamil HCl, CALAN SR, given in the morning.Lower initial doses of 120 mg a
day may be warranted in patients who may have an increased response to verapamil
(eg, the elderly or small people).Upward titration should be based on therapeutic
efficacy and safety evaluated weekly and approximately 24 hours after the previous
dose.The antihypertensive effects of CALAN SR are evident within the first week
If adequate response is not obtained with 180 mg of CALAN SR, the dose may be titrated upward in the following manner:
When switching from immediate-release CALAN to CALAN SR, the total daily dose in milligrams may remain the same.
Overdose with verapamil may lead to pronounced
hypotension, bradycardia, and conduction system abnormalities (eg, junctional
rhythm with AV dissociation and high degree AV block, including asystole).
Other symptoms secondary to hypoperfusion (eg, metabolic acidosis,
hyperglycemia, hyperkalemia, renal dysfunction, and convulsions) may be
Treat all verapamil overdoses as serious and maintain observation for at least 48 hours (especially CALAN SR), preferably under continuous hospital care.Delayed pharmacodynamic consequences may occur with the sustained-release formulation.Verapamil is known to decrease gastrointestinal transit time.
In overdose, caplets of CALAN SR have occasionally been reported to form concretions within the stomach or intestines.These concretions have not been visible on plain radiographs of the abdomen, and no medical means of gastrointestinal emptying is of proven efficacy in removing them.Endoscopy might reasonably be considered in cases of massive overdose when symptoms are unusually prolonged.
Treatment of overdosage should be supportive.Beta-adrenergic stimulation or parenteral administration of calcium solutions may increase calcium ion flux across the slow channel and have been used effectively in treatment of deliberate overdosage with verapamil.Continued treatment with large doses of calcium may produce a response.In a few reported cases, overdose with calcium channel blockers that was initially refractory to atropine became more responsive to this treatment when the patients received large doses (close to 1 g/hr for more than 24 hr) of calcium chloride. Verapamil cannot be removed by hemodialysis.Clinically significant hypotensive reactions or high degree AV block should be treated with vasopressor agents or cardiac pacing, respectively.Asystole should be handled by the usual measures including cardiopulmonary resuscitation.
The use of HMG-CoA reductase inhibitors that are CYP3A4
substrates in combination with verapamil has been associated with reports of myopathy/rhabdomyolysis.
Co-administration of multiple doses of 10 mg of verapamil with 80 mg simvastatin resulted in exposure to simvastatin 2.5-fold that following simvastatin alone.Limit the dose of simvastatin in patients on verapamil to 10 mg daily.Limit the daily dose of lovastatin to 40 mg.Lower starting and maintenance doses of other CYP3A4 substrates (e.g., atorvastatin) may be required as verapamil may increase the plasma concentration of these drugs.
Concomitant therapy with beta-adrenergic blockers and
verapamil may result in additive negative effects on heart rate,
atrioventricular conduction and/or cardiac contractility.The combination of
sustained-release verapamil and beta-adrenergic blocking agents has not been
studied.However, there have been reports of excessive bradycardia and AV
block, including complete heart block, when the combination has been used for
the treatment of hypertension.For hypertensive patients, the risks of combined
therapy may outweigh the potential benefits.The combination should be used only
with caution and close monitoring.
Asymptomatic bradycardia (36 beats/min) with a wandering atrial pacemaker has been observed in a patient receiving concomitant timolol (a beta-adrenergic blocker) eyedrops and oral verapamil.
A decrease in metoprolol and propranolol clearance has been observed when either drug is administered concomitantly with verapamil.A variable effect has been seen when verapamil and atenolol were given together.
Clinical use of verapamil in digitalized patients has shown the combination to be well tolerated if digoxin doses are properly adjusted.However, chronic verapamil treatment can increase serum digoxin levels by 50% to 75% during the first week of therapy, and this can result in digitalis toxicity.In patients with hepatic cirrhosis the influence of verapamil on digoxin kinetics is magnified.Verapamil may reduce total body clearance and extrarenal clearance of digitoxin by 27% and 29%, respectively.Maintenance and digitalization doses should be reduced when verapamil is administered, and the patient should be carefully monitored to avoid over- or under-digitalization.Whenever over-digitalization is suspected, the daily dose of digitalis should be reduced or temporarily discontinued.On discontinuation of CALAN use, the patient should be reassessed to avoid under-digitalization.
Verapamil administered concomitantly with oral antihypertensive agents (eg, vasodilators, angiotensin-converting enzyme inhibitors, diuretics, beta-blockers) will usually have an additive effect on lowering blood pressure. Patients receiving these combinations should be appropriately monitored. Concomitant use of agents that attenuate alpha-adrenergic function with verapamil may result in a reduction in blood pressure that is excessive in some patients. Such an effect was observed in one study following the concomitant administration of verapamil and prazosin.
Disopyramide: Until data on possible interactions
between verapamil and disopyramide phosphate are obtained, disopyramide should
not be administered within 48 hours before or 24 hours after verapamil
Flecainide: A study in healthy volunteers showed that the concomitant administration of flecainide and verapamil may have additive effects on myocardial contractility, AV conduction, and repolarization.Concomitant therapy with flecainide and verapamil may result in additive negative inotropic effect and prolongation of atrioventricular conduction.
Quinidine: In a small number of patients with hypertrophic cardiomyopathy (IHSS), concomitant use of verapamil and quinidine resulted in significant hypotension.Until further data are obtained, combined therapy of verapamil and quinidine in patients with hypertrophic cardiomyopathy should probably be avoided.
The electrophysiologic effects of quinidine and verapamil on AV conduction were studied in 8 patients.Verapamil significantly counteracted the effects of quinidine on AV conduction.There has been a report of increased quinidine levels during verapamil therapy.
Alcohol: Verapamil has been found to inhibit
ethanol elimination significantly, resulting in elevated blood ethanol
concentrations that may prolong the intoxicating effects of alcohol (see CLINICAL
PHARMACOLOGY, Pharmacokinetics and metabolism).
Nitrates: Verapamil has been given concomitantly with short- and long-acting nitrates without any undesirable drug interactions. The pharmacologic profile of both drugs and the clinical experience suggest beneficial interactions.
Cimetidine: The interaction between cimetidine and chronically administered verapamil has not been studied.Variable results on clearance have been obtained in acute studies of healthy volunteers;clearance of verapamil was either reduced or unchanged.
Lithium: Increased sensitivity to the effects of lithium (neurotoxicity) has been reported during concomitant verapamil-lithium therapy;lithium levels have been observed sometimes to increase, sometimes to decrease, and sometimes to be unchanged.Patients receiving both drugs must be monitored carefully.
Carbamazepine: Verapamil therapy may increase carbamazepine concentrations during combined therapy.This may produce carbamazepine side effects such as diplopia, headache, ataxia, or dizziness.
Rifampin: Therapy with rifampin may markedly reduce oral verapamil bioavailability.
Phenobarbital: Phenobarbital therapy may increase verapamil clearance.
Cyclosporin: Verapamil therapy may increase serum levels of cyclosporin.
Theophylline: Verapamil may inhibit the clearance and increase the plasma levels of theophylline.
Inhalation anesthetics: Animal experiments have shown that inhalation anesthetics depress cardiovascular activity by decreasing the inward movement of calcium ions.When used concomitantly, inhalation anesthetics and calcium antagonists, such as verapamil, should each be titrated carefully to avoid excessive cardiovascular depression.
Neuromuscular blocking agents: Clinical data and animal studies suggest that verapamil may potentiate the activity of neuromuscular blocking agents (curare-like and depolarizing).It may be necessary to decrease the dose of verapamil and/or the dose of the neuromuscular blocking agent when the drugs are used concomitantly.
Telithromycin: Hypotension and bradyarrhythmias have been observed in patients receiving concurrent telithromycin, an antibiotic in the ketolide class.
Clonidine: Sinus bradycardia resulting in hospitalization and pacemaker insertion has been reported in association with the use of clonidine concurrently with verapamil.Monitor heart rate in patients receiving concomitant verapamil and clonidine.
No information provided.Please refer to the WARNINGS and PRECAUTIONS sections.
CALAN SR 120 mg caplets are light violet, oval, film
coated, with CALAN debossed on one side and SR 120 on the other, supplied as:
|0025-1901-31||bottle of 100|
|0025-1911-31||bottle of 100|
|0025-1891-31||bottle of 100|
|0025-1891-51||bottle of 500|
|Pharmacotherapeutic group Chemical name Description Clinical Pharmacology Indications ContraIndications Warnings Precautions Side effects Dosage and administration Overdosage Drug interactions Patient Information How Supplied Storage conditions And Handling|
|Medication Analogs Generic Name||medicines of the ATC group|