Veral Special Precautions

Myocardial infarction: Use with caution in acute myocardial infarction with complications (bradycardia, hypotension, left ventricular dysfunction).
Conduction disturbance/AV block degree I/bradycardia/asystole: Verapamil hydrochloride affects the AV and sinus nodes and prolongs AV conduction time. Use with caution as development of second- or third-degree AV block (Contraindication) or unifascicular, bifascicular or trifascicular bundle branch block requires discontinuation of verapamil hydrochloride and institution of appropriate therapy, if needed.
Verapamil hydrochloride affects the AV and sinus nodes and rarely may produce second- or third-degree AV block, bradycardia, or, in extreme cases, asystole. This is more likely to occur in patients with a sick sinus syndrome, which is more common in older patients.
Asystole in patients other than those with sick sinus syndrome is usually of short duration (few seconds or less), with spontaneous return to AV nodal or normal sinus rhythm. If this does not occur promptly, appropriate treatment should be initiated immediately (see Adverse Reactions).
Anti-arrhythmics, beta-blockers and inhalation anaesthetics: Anti-arrhythmics (e.g. flecainide, disopyramide), beta-receptor blockers (e.g. metoprolol, propranolol) and inhalation anaesthetics may cause mutual potentiation of cardiovascular effects (higher-grade AV block, higher-grade lowering of heart rate, induction of heart failure and potentiated hypotension (see Interactions).
Asymptomatic bradycardia (36 beats/minute) with a wandering atrial pacemaker has been observed in a patient receiving concomitant timolol (a beta-adrenergic blocker) eye drops and oral verapamil hydrochloride.
Digoxin: If verapamil is administered concomitantly with digoxin, digoxin dose is to be reduced (see Interactions).
Cardiac insufficiency: Cardiac insufficiency patients with ejection fraction higher than 35% should be compensated before starting verapamil treatment and should be adequately treated throughout.
HMG-CoA reductase inhibitors ("statins"): See Interactions.
Neuromuscular transmission disorders: Verapamil hydrochloride 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).
Hypotension: In hypotension (less than 90 mmHg systolic blood pressure), extra careful monitoring is required.
Special populations: Impaired renal function: Although comparison studies have reliably shown that impaired renal function in patients with end-stage renal failure has no effect on the pharmacokinetics of verapamil, isolated case reports have suggested that verapamil should only be used with caution and with careful monitoring (ECG, blood pressure) in patients with impaired renal function.
Verapamil cannot be removed via haemodialysis.
Impaired liver function: Use with caution in patients with severely impaired liver function (see Dosage & Administration).
Effects on ability to drive and use machines: Treatment with verapamil requires regular medical monitoring. Due to inter-individually different reactions, reactivity may be impaired to such an extent that the ability to drive to operate machinery or to work in an unsafe posture is impaired. This applies to a higher degree when starting therapy, increasing the dose and changing the preparation as well as in conjunction with alcohol.
Verapamil may increase the blood levels of alcohol and slow its elimination. Therefore, the effects of alcohol may be exaggerated.