1. Name Of The Medicinal Product
Univer 120mg Prolonged-release Hard Capsules
Univer 180mg Prolonged-release Hard Capsules
Univer 240mg Prolonged-release Hard Capsules
2. Qualitative And Quantitative Composition
Verapamil hydrochloride 120 mg.
Verapamil hydrochloride 180 mg.
Verapamil hydrochloride 240 mg.
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For a full list of excipients, see section 6.1.
3. Pharmaceutical Form
Prolonged-release capsule, hard.
Capsules are blue and yellow and printed with V120.
Capsules are yellow and printed with V180.
Capsules are blue and yellow and printed with V240.
4. Clinical Particulars
4.1 Therapeutic Indications
Mild to moderate hypertension. Angina pectoris.
4.2 Posology And Method Of Administration
For oral administration only. The capsules should be swallowed whole and not chewed.
The bioequivalence of Univer to other prolonged release verapamil formulations may not have been evaluated. As such, this product should not be directly substituted for other non-identical formulations of verapamil and vice-versa.
Adults:
Mild to moderate hypertension: Initial dose in adult patients new to verapamil therapy should be 120 mg once daily. This can be increased to 240 mg once daily which is the normal maintenance dosage. The dose may be further increased to a maximum of 480 mg once daily if required.
Angina: The usual adult dose is 360 mg once daily. Dosage may be increased to a maximum of 480 mg daily if required.
Elderly: Elderly patients show enhanced bioavailability of verapamil and therapeutic control may be achieved with lower doses in this patient population.
Children: Not recommended in children and adolescents under the age of 18 years.
Hepatic impairment: Verapamil is extensively metabolised in the liver and for those patients with impaired liver function, the dose should be reduced and carefully titrated.
Renal impairment: About 70% of an administered dose of verapamil is excreted as metabolites in the urine. Verapamil should be prescribed cautiously when renal function is impaired. Careful patient monitoring is recommended.
4.3 Contraindications
• Acute myocardial infarction with complications such as bradycardia, hypotension, left ventricular decompensation or congestive heart failure.
• Second or third degree atrioventricular block without pacemaker.
• Sick sinus syndrome, sino-atrial block, or sinus bradycardia of less than 50 beats/minute (except in patients with functioning artificial ventricular pacemaker).
• Uncompensated cardiac failure.
• Atrial flutter or atrial fibrillation associated with an accessory pathway (e.g. Wolff-Parkinson-White, Lown-Ganong-Levine syndrome).
• Porphyria.
• Hypotension (systolic pressure <90 mm Hg) or cardiogenic shock.
• Intravenous dantrolene (see section 4.5).
• Known hypersensitivity to the active substance or to any of the excipients.
• Concomitant ingestion of grapefruit juice.
4.4 Special Warnings And Precautions For Use
Special care should be taken in hypotension (see section 4.3), especially in acute myocardial infarction as this is a condition where atrioventricular conduction defects may develop and contractility may be impaired.
Use with caution in patients with first degree atrioventricular block or bradycardia.
Left ventricular contractility may be affected and although the effect is small, cardiac failure may be precipitated or aggravated. Hence incipient cardiac failure should be controlled using appropriate therapy before verapamil is given.
Caution should be exercised in treatment with HMG CoA reductase inhibitors (e.g., simvastatin, atorvastatin or lovastatin) for patients taking verapamil. These patients should be started at the lowest possible dose of verapamil and titrated upwards. If verapamil treatment is to be added to patients already taking an HMG CoA reductase inhibitor (e.g., simvastatin, atorvastatin or lovastatin), refer to advice in the respective statin product information (see section 4.5 Interaction with other medicinal products and other forms of interaction).
Verapamil is extensively metabolised in the liver and special care should be taken in cases where liver damage exists, as plasma levels of verapamil may be increased (see section 4.2).
There have been reports of calcium-channel blockers exacerbating muscle weakness in patients with myasthenia gravis. Verapamil should be used with caution in the presence of diseases in which neuromuscular transmission is affected (myasthenia gravis, Lambert-Eaton syndrome, advanced Duchenne muscular dystrophy).
Verapamil is not removed during dialysis.
Owing to the presence of sucrose, patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
In vitro metabolic studies indicate that verapamil hydrochloride is metabolized by cytochrome P450 CYP3A4, CYP1A2, CYP2C8, CYP2C9 and CYP2C18. Verapamil has been shown to be an inhibitor of CYP3A4 enzymes and P-glycoprotein (P-gp). Clinically significant interactions have been reported with inhibitors of CYP3A4 causing elevation of plasma levels of verapamil hydrochloride while inducers of CYP3A4 have caused a lowering of plasma levels of verapamil hydrochloride, therefore, patients should be monitored for drug interactions.
Concomitant use contra-indicated
Dantrolene: the association of this muscle relaxant given intravenously and verapamil is potentially dangerous (can cause fatal ventricular fibrillation in animals) and is contraindicated.
Intravenous beta-blockers should not be given to patients under treatment with verapamil.
Other relevant interactions
Acetylsalicylic acid
Concomitant use of verapamil with aspirin may increase the risk of bleeding
Alcohol
Alcohol: an increase in blood alcohol and slowed elimination has been reported.
Alpha blockers
Verapamil may increase the plasma concentrations of prazosin and terazosin which may have an additive hypotensive effect.
Antiarrhythmics
Verapamil may slightly decrease the plasma clearance of flecainide whereas flecainide has no effect on the verapamil plasma clearance. Verapamil may increase the plasma concentrations of quinidine. Pulmonary oedema may occur in patients with hypertrophic cardiomyopathy The combination of verapamil and antiarrhythmic agents may lead to additive cardiovascular effects (e.g. AV block, bradycardia, hypotension, heart failure).
Anticonvulsants
Verapamil may increase the plasma concentrations of carbamazepine. This may produce side effects such as diplopia, headache, ataxia or dizziness. Verapamil may also increase the plasma concentrations of phenytoin.
Antidepressants
Verapamil may increase the plasma concentrations of imipramine.
Antidiabetics
Verapamil may increase the plasma concentrations of glibenclamide (glyburide).
Antihypertensives, diuretics, vasodilators
Potentiation of the hypotensive effect.
Anti-infectives
Rifampicin may reduce the plasma concentrations of verapamil which may produce a reduced blood pressure lowering effect. Ketoconozole, erythromycin, clarithromycin and telithromycin may increase the plasma concentrations of verapamil.
Antineoplastics
Verapamil may increase the plasma concentrations of doxorubicin.
Barbiturates
Phenobarbital may reduce the plasma concentrations of verapamil.
Benzodiazepines and other anxiolytics
Verapamil may increase the plasma concentrations of buspirone and midazolam.
Beta blockers
Verapamil may increase the plasma concentrations of metoprolol and propranolol which may lead to additive cardiovascular effects (e.g. AV block, bradycardia, hypotension, heart failure).
A period between stopping beta-blocking therapy and starting therapy with this product may be advisable. Concomitant use of verapamil and beta-blockers or antiarrhythmics, if necessary, should only be administered to patients in a closely monitored clinical setting.
The effects of verapamil may be additive to other hypotensive agents.
Cardiac glycosides
Verapamil may increase the plasma concentrations of digitoxin and digoxin. Verapamil has been shown to increase the serum concentration of digoxin and caution should be exercised with regard to digitalis toxicity. The digitalis level should be determined and the glycoside dose reduced, if required.
Colchicine
Colchicine is a substrate for both CYP3A and the efflux transporter, P-glycoprotein (P-gp). Verapamil is known to inhibit CYP3A and Pgp. When verapamil and colchicine are administered together, inhibition of P-gp and/or CYP3A by verapamil may lead to increased exposure to colchicine. Combined use is not recommended.
H2 Receptor antagonists
Cimetidine may increase the plasma concentrations of verapamil.
HIV antiviral agents
Due to the metabolic inhibitory potential of some of the HIV antiviral agents, such as ritonavir, plasma concentrations of verapamil may increase. Caution should be used or dose of verapamil may be decreased.
Immunosuppressants
Verapamil may increase the plasma concentrations of ciclosporin, everolimus, sirolimus and tacrolimus.
Inhaled anaesthetics
When used concomitantly, inhalation anaesthetics and calcium antagonists, such as verapamil hydrochloride, should each be titrated carefully to avoid additive cardiovascular effects (e.g. AV block, bradycardia, hypotension, heart failure).
Lipid lowering agents
Verapamil may increase the plasma concentrations of atorvastatin, lovastatin and simvastatin. Treatment with HMG CoA reductase inhibitors (e.g., simvastatin, atorvastatin or lovastatin) in a patient taking verapamil should be started at the lowest possible dose and titrated upwards. If verapamil treatment is to be added to patients already taking an HMG CoA reductase inhibitor (e.g., simvastatin, atorvastatin or lovastatin), consider a reduction in the statin dose and retitrate against serum cholesterol concentrations. Atorvastatin has been shown to increase verapamil levels. Although there is no direct in vivo clinical evidence, there is strong potential for verapamil to significantly affect atorvastatin pharmacokinetics in a similar manner to simvastatin or lovastatin. Consider using caution when atorvastatin and verapamil are concomitantly administered. Fluvastatin, pravastatin and rosuvastatin are not metabolized by CYP3A4 and are less likely to interact with verapamil.
Lithium
Serum levels of lithium may be reduced. However, there may be increased sensitivity to lithium causing enhanced neurotoxicity. Lithium can enhance neuromuscular block during anaesthesia and hence verapamil with lithium may potentiate the neuromuscular blocking effect.
Neuromuscular blocking agents employed in anaesthesia
The effects may be potentiated.
Serotonin receptor agonists
Verapamil may increase the plasma concentrations of almotriptan.
Theophylline
Verapamil may increase the plasma concentrations of theophylline.
Uricosurics
Sulfinpyrazone may reduce the plasma concentrations of verapamil which may produce a reduced blood pressure lowering effect.
Other
St. John's Wort may reduce the plasma concentrations of verapamil, whereas grapefruit juice may increase the plasma concentrations of verapamil.
4.6 Pregnancy And Lactation
Animal studies have shown no teratogenic effects and data on a limited number of exposed pregnancies showed no adverse effects on the health of the foetus or newborn child.
Caution should be exercised, however, when prescribing to pregnant women and verapamil should be avoided in the first trimester unless the benefits clearly outweigh the risks.
Verapamil is excreted into the breast milk in small amounts and is unlikely to be harmful. However, it should only be used during lactation if, in the clinicians judgement, it is essential for the welfare of the patient.
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 or work under hazardous conditions may be impaired. This is particularly true in the initial stages of treatment, when changing over from another drug or when the dose is raised. 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
Reactions from Postmarketing Surveillance or Phase IV Clinical Trials
The following adverse events reported with verapamil are listed below by system organ class:
Immune system disorders: allergic reactions (e.g. erythema, pruritus, urticaria) are very rarely seen.
Nervous system disorders: headache, dizziness, paresthesia, tremor and extrapyramidal syndrome.
Ear and labyrinth disorders: vertigo and tinnitus.
Cardiac disorders/vascular disorders: bradycardic arrhythmias such as sinus bradycardia, sinus arrest with asystole, 2nd and 3rd degree AV block, bradyarrhythmia in atrial fibrillation, peripheral oedema, palpitations, tachycardia, development or aggravation of heart failure and hypotension. There have been rare reports of flushing.
Gastrointestinal disorders: nausea, vomiting, constipation, ileus and abdominal pain/discomfort. Gingival hyperplasia may occur very rarely when the drug is administered over prolonged periods, and is fully reversible when the drug is discontinued.
Skin and subcutaneous tissue disorders: ankle oedema, Quincke's oedema, Steven-Johnson syndrome, erythema multiforme, erythromelalgia, alopecia and purpura.
Musculoskeletal and connective tissue disorders: muscular weakness, myalgia and arthralgia.
Reproductive system and breast disorders: impotence (erectile dysfunction) has been rarely reported and isolated cases of galactorrhoea. On very rare occasions, gynaecomastia has been observed in elderly male patients under long-term verapamil treatment, and is fully reversible in all cases when the drug was discontinued.
General disorders and administration site conditions: fatigue.
Investigations: A reversible impairment of liver function characterized by an increase of transaminase and/or alkaline phosphatase may occur on very rare occasions during verapamil treatment and is most probably a hypersensitivity reaction. Rises in blood prolactin levels have been reported.
4.9 Overdose
The course of symptoms in verapamil intoxication depends on the amount taken, the point in time at which detoxification measures are taken and myocardial contractility (age-related). The main symptoms are as follows: blood pressure fall (at times to values not detectable), shock symptoms, loss of consciousness, 1st and 2nd degree AV block (frequently as Wenckebach's phenomenon with or without escape rhythms), total AV block with total AV dissociation, escape rhythm, asystole, bradycardia up to high degree AV block and, sinus arrest, hyperglycaemia, stupor and metabolic acidosis. Fatalities have occurred as a result of overdose.
In intoxications with large amounts of slow-release preparations, it should be noted that the release of the active drug and the absorption in the intestine may take more than 48 hours. Verapamil hydrochloride cannot be removed by haemodialysis.
General measures to be taken: Gastric lavage with the usual precautions, even later than 12 hours after ingestion, if no gastrointestinal motility (peristaltic sounds) is detectable. Where intoxication with Univer is suspected, extensive elimination measures are indicated, such as induced vomiting, removal of the contents of the stomach and the small intestine under endoscopy, intestinal lavage, laxative, high enemas. The usual intensive resuscitation measures apply, such as extrathoracic heart massage, respiration, defibrillation and/or pacemaker therapy.
Specific measures to be taken: Elimination of cardiodepressive effects, hypotension or bradycardia. The specific antidote is calcium, e.g. 10-20 ml of a 10% calcium gluconate solution administered intravenously.
The following measures may also be necessary: In case of 2nd or 3rd degree AV block, sinus bradycardia, asystole - atropine, isoprenaline, orciprenaline or pacemaker therapy. In case of hypotension - dopamine, dobutamine, noradrenaline. If there are signs of continuing myocardial failure - dopamine, dobutamine, if necessary repeated calcium injections.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Pharmacotherapeutic group: Calcium channel blockers, Phenylalkylamine derivatives, ATC code: C08D A01.
Verapamil is a phenylalkylamine calcium antagonist with effects upon arterial smooth muscle, myocardial cells and cells of the cardiac conduction system. It lowers heart rate, increases myocardial perfusion and reduces coronary spasm. It decreases vascular peripheral resistance and lowers blood pressure by vasodilation without reflex tachycardia. The effects are more pronounced on high blood pressure than on normal pressure because of its use-dependent action on the voltage-operated calcium channel.
5.2 Pharmacokinetic Properties
Approximately 90% of verapamil is absorbed following oral administration and is subject to extensive first pass metabolism in the liver. There is considerable interindividual variation in plasma concentrations. About 70% of the oral dose is excreted by the kidneys and 16% with the faeces.
Where liver damage exists plasma levels of verapamil may be increased. Renal failure does not significantly alter the kinetics of the drug. Elderly subjects show enhanced bioavailability of verapamil.
Univer provides prolonged release of verapamil in the gastrointestinal tract and a pharmacokinetic profile consistent with a prolonged release formulation. A study in healthy volunteers compared the pharmacokinetics of Univer 240 mg administered once daily and immediate-release verapamil 80 mg administered three times daily. The comparative steady state kinetic data are shown below:
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5.3 Preclinical Safety Data
There is no evidence of teratogenicity or carcinogenicity with verapamil. There are no additional preclinical safety data of relevance to the prescriber.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Capsule contents:
Fumaric acid
Sugar spheres (containing sucrose and maize starch)
Talc
Povidone
Shellac
Capsule shell:
Gelatin
Titanium dioxide (E171)
Erythrosine (E127)
Indigotine (E132)
Yellow iron oxide (E172)
Printing ink:
Titanium dioxide (E171)
Black iron oxide (E172)
Shellac
Propylene glycol (E1520)
6.2 Incompatibilities
None stated.
6.3 Shelf Life
2 years.
6.4 Special Precautions For Storage
Do not store above 25°C. Store in the original package.
6.5 Nature And Contents Of Container
PVC/aluminium blister packs of 4, 8, 28 or 56 capsules.
Containers of 100 or 500.
6.6 Special Precautions For Disposal And Other Handling
None
7. Marketing Authorisation Holder
Cephalon UK Limited
1 Albany Place
Hyde Way
Welwyn Garden City
Hertfordshire
AL7 3BT
8. Marketing Authorisation Number(S)
Univer 120 mg – PL 16260/0025
Univer 180 mg – PL 16260/0026
Univer 240 mg – PL 16260/0027
9. Date Of First Authorisation/Renewal Of The Authorisation
22nd March 2010
10. Date Of Revision Of The Text
11th March 2011
11. LEGAL CATEGORY
POM
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