page154
Prophylaxis of cluster headache [unlicensed] (under
specialist supervision),
240–960 mg daily in 3–4
divided doses
. By slow intravenous injection over 2 minutes (3
minutes in elderly), supraventricular arrhythmias (but
see also Contra-indications), 5–10 mg (preferably with
ECG monitoring);
in paroxysmal tachyarrhythmias a
further 5 mg after 5–10 minutes if required
Verapamil
(Non-proprietary) A
Tablets
,
coated,
verapamil hydrochloride 40 mg,
net
price 84-tab pack = £1.55; 80 mg, 84-tab pack = £1.91;
120 mg,
28-tab pack = £1.54;
160 mg,
56-tab pack =
£28.20
Oral solution
,
verapamil hydrochloride 40 mg/5 mL,
net price 150 mL = £36.90
Brands include
Zolvera
c
Cordilox
c
(Dexcel) A
Tablets
,
yellow,
f/c,
verapamil hydrochloride 40 mg,
net price 84-tab pack = £1.50;
80 mg,
84-tab pack =
£2.05;
120 mg,
28-tab pack = £1.15;
160 mg,
56-tab
pack = £2.80
Injection
,
verapamil hydrochloride 2.5 mg/mL,
net
price 2-mL amp = £1.11
Securon
c
(Abbott) A
Injection
,
verapamil hydrochloride 2.5 mg/mL,
net
price 2-mL amp = £1.08
Modified release
Half Securon SR
c
(Abbott) A
Tablets
,
m/r,
f/c,
verapamil hydrochloride 120 mg,
net price 28-tab pack = £7.71.
Label:
25
Dose
see
Securon SR
c
Securon SR
c
(Abbott) A
Tablets
,
m/r,
pale green,
f/c,
scored,
verapamil
hydrochloride 240 mg,
net price 28-tab pack = £5.00.
Label:
25
Dose
hypertension, 240 mg daily (new patients initially 120 mg),
increased if necessary to max. 480 mg daily (doses above 240 mg
daily as 2 divided doses)
Angina,
240 mg twice daily (may sometimes be reduced to once
daily)
Prophylaxis after myocardial infarction where beta-blockers not
appropriate (started at least 1 week after infarction), 360 mg daily
in divided doses, given as 240 mg in the morning and 120 mg in
the evening
or
120 mg 3 times daily
Univer
c
(Cephalon) A
Capsules
,
m/r,
verapamil hydrochloride 120 mg
(yellow/dark blue),
net price 28-cap pack = £4.86;
180 mg (yellow), 56-cap pack = £11.38;
240 mg (yel-
low/dark blue),
28-cap pack = £7.67.
Label:
25
Dose
hypertension,
240 mg daily,
max.
480 mg daily (new
patients,
initial
dose 120 mg);
angina,
360 mg daily,
max.
480 mg
daily
Verapress MR
c
(Dexcel) A
Tablets
, m/r, pale green, f/c, verapamil hydrochloride
240 mg,
net price 28-tab pack = £6.04.
Label:
25
Dose
hypertension,
1 tablet daily,
increased to twice daily if
necessary;
angina,
1 tablet twice daily (may sometimes be
reduced to once daily)
Note
Also available as
Cordilox
c
MR
Vertab
c
SR 240
(Chiesi) A
Tablets
,
m/r,
pale green,
f/c,
scored,
verapamil
hydrochloride 240 mg,
net price 28-tab pack = £5.45.
Label:
25
Dose
mild to moderate hypertension, 240 mg daily, increased to
twice daily if necessary;
angina,
240 mg twice daily (may some-
times be reduced to once daily)
2.6.3
Other antianginal drugs
Nicorandil, a potassium-channel activator with a nitrate
component,
has both arterial
and venous vasodilating
properties and is licensed for the prevention and long-
term treatment
of
angina (section 2.10.1).
Nicorandil
has similar efficacy to other antianginal
drugs in con-
trolling symptoms;
it may produce additional
sympto-
matic benefit
in combination with other
antianginal
drugs [unlicensed indication].
Ivabradine lowers the heart
rate by its action on the
sinus node.
It is licensed for the treatment of angina in
patients in normal
sinus rhythm in combination with a
beta-blocker,
or
when beta-blockers
are contra-indi-
cated or not tolerated.
Ranolazine is licensed as adjunctive therapy in patients
who are inadequately controlled or intolerant
of
first-
line antianginal drugs.
IVABRADINE
Indications
treatment of angina in patients in normal
sinus rhythm (see notes above)
Cautions
mild heart failure including asymptomatic
left ventricular dysfunction;
monitor for atrial fibrilla-
tion or other arrhythmias (treatment ineffective);
hypotension (avoid if severe);
retinitis pigmentosa;
elderly;
interactions:
Appendix 1 (ivabradine)
Contra-indications
severe bradycardia (not to be
initiated if heart rate below 60 beats per minute);
cardiogenic shock;
acute myocardial infarction;
immediately after cerebrovascular accident;
sick-
sinus syndrome; sino-atrial block; moderate to severe
heart failure;
patients with pacemaker; unstable
angina;
second- and third-degree heart block;
conge-
nital QT syndrome
Hepatic impairment
manufacturer advises caution in
moderate impairment;
avoid in severe impairment
Renal impairment
manufacturer advises use with
caution if eGFR less than 15 mL/minute/1.73 m
2
—no
information available
Pregnancy
manufacturer advises avoid—toxicity in
animal
studies
Breast-feeding
present in milk in
animal
studies—
manufacturer advises avoid
Side-effects
bradycardia, first-degree heart block,
ventricular extrasystoles;
headache,
dizziness;
visual
disturbances including phosphenes and blurred
vision;
less commonly
nausea,
constipation,
diarr-
hoea,
palpitations,
supraventricular extrasystoles,
dyspnoea,
vertigo,
muscle cramps,
eosinophilia,
hyperuricaemia,
and raised plasma-creatinine con-
centration
Dose
. Initially 5 mg twice daily,
increased if necessary after
3–4 weeks to 7.5 mg twice daily (if not tolerated
reduce dose to 2.5–5 mg twice daily);
ELDERLY
initially
2.5 mg twice daily
Note
Ventricular rate at rest should not be allowed to fall
below 50 beats per minute
Procoralan
c
(Servier) T A
Tablets
, pink, f/c, ivabradine (as hydrochloride) 5 mg
(scored),
net price 56-tab pack = £39.00;
7.5 mg,
56-
tab pack = £39.00
134
2.6.3 Other antianginal drugs
BNF 61
2
Cardiovascular system