There has been a report of increased quinidine levels during verapamil therapy. Aspirin In a few reported cases, coadministration of verapamil with aspirin has led to increased bleeding times greater than observed with aspirin alone. Antihypertensive agents Verapamil administered concomitantly with oral antihypertensive agents e. Monitor patients receiving these combinations appropriately. Concomitant use of agents that attenuate alpha-adrenergic function with verapamil may result in 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 are obtained, do not administer disopyramide within 48 hours before or 24 hours after verapamil administration.

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. Carbamazepine Verapamil therapy may increase carbamazepine concentrations during combined therapy.

This may produce carbamazepine side effects such as diplopia , headache, ataxia , or dizziness. Cyclosporine Verapamil therapy may increase serum levels of cyclosporine. Lithium Increased sensitivity to the effects of lithium neurotoxicity has been reported during concomitant verapamil-lithium therapy with either no change or an increase in serum lithium levels.

However, the addition of verapamil has also resulted in the lowering of serum lithium levels in patients receiving chronic stable oral lithium. Patients receiving both drugs must be monitored carefully.

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, titrate slowly 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. Phenobarbital Phenobarbital therapy may increase verapamil clearance. Rifampin Therapy with rifampin may markedly reduce oral verapamil bioavailability. Theophylline Verapamil may inhibit the clearance and increase the plasma levels of theophylline.

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.

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. In previous clinical experience with 4, patients primarily with immediate-release verapamil, 87 1. Avoid verapamil in patients with severe left ventricular dysfunction e. Hypotension Occasionally, the pharmacologic action of verapamil may produce a decrease in blood pressure below normal levels which may result in dizziness or symptomatic hypotension.

In hypertensive patients, decreases in blood pressure below normal are unusual. The incidence of hypotension observed in 4, patients enrolled in clinical trials of other verapamil formulations was 2. In clinical studies of Verelan PM, 1. Tilt table testing 60 degrees was not able to induce orthostatic hypotension.

Elevated Liver Enzymes 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.

Periodic monitoring of liver function in patients receiving verapamil is therefore prudent. Treatment is usually DC- cardioversion. Cardioversion has been used safely and effectively after oral verapamil. Atrioventricular Block The effect of verapamil on AV conduction and the SA node may lead to 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. Marked first-degree block or progressive development to second-or third-degree AV block requires a reduction in dosage or, in rare instances, discontinuation of verapamil and institution of appropriate therapy depending upon the clinical situation.

Three patients died in pulmonary edema; all had severe left ventricular outflow obstruction and a history of left ventricular dysfunction. 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 have to be discontinued.

Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment Of Fertility An 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.

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 6. Effects on male fertility have not been determined. 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. Verapamil should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Verapamil crosses the placental barrier and can be detected in umbilical vein blood at delivery. Labor And 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. Nursing Mothers Verapamil is excreted into human milk. In case studies where verapamil concentration in human milk was calculated, the nursing infant doses ranged from less than 0.

Consider possible infant exposure when verapamil is administered to a nursing woman. Pediatric Use Safety and effectiveness in pediatric patients have not been established. Geriatric Use Clinical studies of Verelan PM were not adequate to determine if subjects aged 65 or over respond differently from younger patients. Other reported clinical experience has not identified differences in response between the elderly and younger patients; however, greater sensitivity to Verelan PM by some older individuals cannot be ruled out.

Aging may affect the pharmacokinetics of verapamil. Clinical circumstances, some of which may be more common in the elderly, such as hepatic or renal impairment, should be considered [see Use In Specific Populations]. Impaired Hepatic Function Since verapamil is highly metabolized by the liver, consider lower dosages and closely monitor responses to the drug in patients with impaired hepatic function.

Attenuated decreased Neuromuscular Transmission 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 and causes a worsening of myasthenia gravis. It may be necessary to decrease the dosage of verapamil when it is administered to patients with attenuated neuromuscular transmission.

Delayed pharmacodynamic consequences may occur with sustained-release formulations, and observe patients for at least 48 hours, preferably under continuous hospital care. Reported effects include hypotension , bradycardia , cardiac conduction defects, arrhythmias, hyperglycemia , and decreased mental status.

In addition, there have been literature reports of noncardiogenic pulmonary edema in patients taking large overdoses of verapamil up to approximately 9 g.

In acute overdosage, consider gastrointestinal decontamination with cathartics and whole bowel irrigation. Calcium chloride is preferred to calcium gluconate since it provides 3 times more calcium per volume. Asystole should be handled by the usual measures including cardiopulmonary resuscitation.

Verapamil cannot be removed by hemodialysis. Hypotension less than 90 mm Hg systolic pressure or cardiogenic shock.

Sick sinus syndrome except in patients with a functioning artificial ventricular pacemaker. Second- or third-degree AV block except in patients with a functioning artificial ventricular pacemaker. There are many factors that can lead to erectile dysfunction. Some of the health conditions that may lead to ED include: Lifestyle choices may also possibly contribute to ED. These may include smoking, excessive alcohol use, being overweight, and lack of exercise. It is important to speak with your health care provider in regards to the symptoms you are experiencing.

When your doctor prescribes a new medication, be sure to discuss all your prescription and over-the-counter drugs, including dietary supplements, vitamins, botanicals, minerals, and herbals, as well as the foods you eat. Always keep a current list of the drugs and supplements you take and review it with your health care providers and your pharmacist. If possible, use one pharmacy for all your prescription medications and over-the-counter products.

This allows your pharmacist to keep a complete record of all your prescription drugs and to advise you about drug interactions and side effects. Tell your health care provider about any negative side effects from prescription drugs.

You can also report them to the U. Food and Drug Administration by visiting www. For more specific information, consult with your doctor for guidance based on your health status and current medications, particularly before taking any action. Kristen Dore, PharmD Q: Does verapamil cause weight gain? Many medications interact with grapefruit and hence its consumption is discouraged when taking medications.

Studies suggest that grapefruit's effects on verapamil is contradictory and unpredictable. Patient's liver function and kidney function also affects this interaction.

Therefore, to be completely safe, it is best to avoid grapefruit juice completely. I take verapamil ER tabs. Is it true that after years of taking high blood pressure medicine it can enlarge your aorta? Verapamil works to keep blood vessels open, making it easier for the heart to pump blood through the body. Verapamil ER is an extended-release form of verapamil that is used to treat high blood pressure. The prescribing information does not specifically list enlarged aorta as a possible long-term side effect of verapamil use.

The aorta is the large blood vessel that comes out of the heart to deliver blood to the body. The aorta can become enlarged at any point over its 2- to 3-foot length. Enlargement of the aorta is generally caused by conditions that change the properties of the blood vessel wall.

The most common causes are cigarette smoking, high blood pressure or hypertension , and high cholesterol levels. Genetics meaning your family history may also play a role. Controlling blood pressure and obtaining appropriate evaluations and diagnostic tests by your healthcare provider is the best way to prevent the aorta from getting larger over time.

I am 67 years old, and I have been taking verapamil along with other medications for hypertension for about 30 years. Are there long-term risks or effects from taking verapamil? Should I ask my doctor to replace verapamil with some of the newer medications for hypertension? Verapamil SR is used to treat high blood pressure.

A search of the prescribing information and medical literature did not identify any significant long-term risks or effects with verapamil that would outweigh its benefits in treating high blood pressure.

However, this does not necessarily mean that there are no long-term risks associated with verapamil use. The most appropriate treatment for high blood pressure often depends on many patient-specific characteristics.

Derek Dore, PharmD Q: Tramadol is in a drug class called opiate agonists. Tramadol is used for the management of moderate to moderately severe pain. Tramadol works by altering pain sensation in the body. The most common side effects with tramadol are: According to tramadol prescribing information, tramadol may impair the mental or physical abilities required to perform potentially hazardous tasks, like driving a motor vehicle or operating machinery.

Caution should be used accordingly.

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