Paroxysmal Supraventricular Tachycardia (PSVT) Treatments

Verapamil hydrochloride, USP is chemically described as benzeneacetonitrile, α [3-[[2-(3,4-dimethoxyphenyl) -ethyl] methylamino] propyl] -3,4-dimethoxy-α -(1-methylethyl)-, monohydrochloride, (±). Its molecular formula is C

Verapamil hydrochloride, USP is a white or practically white crystalline powder, with a molecular weight of 491.06 g/mol. It is soluble in water, freely soluble in chloroform, sparingly soluble in alcohol and practically insoluble in ether. It is practically odorless and has a bitter taste.

Trandolapril, USP is the ethyl ester prodrug of a nonsulfhydryl angiotensin converting enzyme (ACE) inhibitor, trandolaprilat. It is chemically described as (2S,3aR,7aS)- 1- [(S)-2-[[(S)-1-(EthoxyCarbonyl)-3-phenylpropyl] amino]Propanoyl]octahydro-1H-indole-2-carboxylic acid. Its molecular formula is C

Trandolapril, USP is a white or almost white powder with a molecular weight of 430.54 g/mol. It is practically insoluble in water; freely soluble in methylene chloride; sparingly soluble in absolute alcohol.

Trandolapril and verapamil hydrochloride extended-release tablets are formulated for oral administration, containing verapamil hydrochloride, USP as a controlled release formulation and trandolapril, USP as an immediate release formulation. The tablet strengths are trandolapril and verapamil hydrochloride extended-release tablets 1 mg/240 mg, trandolapril and verapamil hydrochloride extended-release tablets 2 mg/180 mg, trandolapril and verapamil hydrochloride extended-release tablets 2 mg/240 mg, and trandolapril and verapamil hydrochloride extended-release tablets 4 mg/240 mg. The tablets also contain the following ingredients: colloidal silicon dioxide, corn starch, croscarmellose sodium, ferric oxide red, hypromellose, lactose monohydrate, povidone, sodium alginate, sodium stearyl fumarate, magnesium stearate, and microcrystalline cellulose. The film coating contains: 1 mg/240 mg – hypromellose, titanium dioxide, and polyethylene glycol; 2 mg/180 mg – hypromellose, titanium dioxide, polyethylene glycol, iron oxide red, and FD&C blue #2; 2 mg/240 mg – hypromellose, titanium dioxide, polyethylene glycol, iron oxide yellow, iron oxide black, and iron oxide red; 4 mg/240 mg – hypromellose, titanium dioxide, polyethylene glycol, iron oxide yellow, iron oxide red, and iron oxide black.

Verapamil is a calcium channel blocker 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. During isometric or dynamic exercise, verapamil does not alter systolic cardiac function in patients with normal ventricular function. Verapamil does not alter total serum calcium levels.

Trandolapril is de-esterified to its diacid metabolite, trandolaprilat. Both inhibit angiotensin-converting enzyme (ACE) in human subjects and in animals. Trandolaprilat is about 8 times more potent than trandolapril. ACE is a peptidyl dipeptidase that catalyzes the conversion of angiotensin I to the vasoconstrictor, angiotensin II. Angiotensin II also stimulates aldosterone secretion by the adrenal cortex.

Inhibition of ACE results in decreased plasma angiotensin II, which leads to decreased vasopressor activity and to decreased aldosterone secretion. The latter decrease may result in a small increase of serum potassium. In controlled clinical trials, treatment with trandolapril and verapamil hydrochloride extended-release tablets resulted in mean increases in potassium of 0.1 mEq/L (see

ACE is identical to kininase II, an enzyme that degrades bradykinin. Whether increased levels of bradykinin, a potent vasodepressor peptide, play a role in the therapeutic effect of trandolapril and verapamil hydrochloride extended-release tablets remains to be elucidated.

While the mechanism through which trandolapril lowers blood pressure is believed to be primarily suppression of the renin-angiotensin-aldosterone system, trandolapril has an antihypertensive effect even in patients with low renin hypertension. Trandolapril is an effective antihypertensive in all races studied. Both black patients (usually a predominantly low renin group) and non-black patients respond to 2 to 4 mg of trandolapril.

Angina, AV block second degree, bundle branch block, edema, flushing, hypotension, myocardial infarction, palpitations, premature ventricular contractions, nonspecific ST-T changes, near syncope, tachycardia.

Drowsiness, hypesthesia, insomnia, loss of balance, paresthesia, vertigo.

Pruritus, rash.

Anxiety, impotence, abnormal mentation.

Epistaxis, tinnitus, upper respiratory tract infection, blurred vision.

Diarrhea, dyspepsia, dry mouth, nausea.

Chest pain, malaise, weakness.

Endometriosis, hematuria, nocturia, polyuria, proteinuria.

Decreased leukocytes, decreased neutrophils.

Arthralgias/myalgias, gout (increased uric acid).

Dyspnea.

Angioedema has been reported in 3 (0.15%) patients receiving trandolapril and verapamil hydrochloride extended-release tablets in U.S. and foreign studies (N = 1,957). Angioedema associated with laryngeal edema may be fatal. If angioedema of the face, extremities, lips, tongue, glottis, and/or larynx occurs, treatment with trandolapril and verapamil hydrochloride extended-release tablets should be discontinued and appropriate therapy instituted immediately (see

(See

The frequency of cardiovascular adverse reactions which require therapy is rare, hence, experience with their treatment is limited. Whenever severe hypotension or complete AV block occur following oral administration of trandolapril and verapamil hydrochloride extended-release tablets (verapamil component), the appropriate emergency measures should be applied immediately, e.g., intravenously administered isoproterenol HCl, levarterenol bitartrate, atropine (all in the usual doses), or calcium gluconate (10% solution). In patients with hypertrophic cardiomyopathy (IHSS), alpha-adrenergic agents (phenylephrine, metaraminol bitartrate or methoxamine) should be used to maintain blood pressure, and isoproterenol and levarterenol should be avoided. If further support is necessary, inotropic agents (dopamine or dobutamine) may be administered. Actual treatment and dosage should depend on the severity and the clinical situation and the judgment and experience of the treating physician.

Other adverse experiences (in addition to those in table and listed above) that have been reported with the individual components are listed below.

There has been a single postmarketing report of paralysis (tetraparesis) associated with the combined use of verapamil and colchicine. This may have been caused by colchicine crossing the blood-brain barrier due to CYP3A4 and P-gp inhibition by verapamil. Combined use of verapamil and colchicine is not recommended (see

Overdose with verapamil may lead to pronounced hypotension, bradycardia, and conduction system abnormalities (e.g., junctional rhythm with AV dissociation and high degree AV block, including asystole). Other symptoms secondary to hypoperfusion (e.g., metabolic acidosis, hyperglycemia, hyperkalemia, renal dysfunction, and convulsions) may be evident.

Treat all verapamil overdoses as serious and maintain observation for at least 48 hours, preferably under continuous hospital care. Delayed pharmacodynamic consequences may occur with the sustained release formulation. Verapamil is known to decrease gastrointestinal transit time. In cases of overdose, verapamil hydrochloride sustained-release tablets 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 overdose when symptoms are unusually prolonged. Verapamil cannot be removed by hemodialysis.

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. The following measures may be considered:

The oral LD

In humans, the most likely clinical manifestation would be symptoms attributable to severe hypotension. Laboratory determinations of serum levels of trandolapril and its metabolites are not widely available, and such determinations have, in any event, no established role in the management of trandolapril overdose. No data are available to suggest that physiological maneuvers (e.g., maneuvers to change pH of the urine) might accelerate elimination of trandolapril and its metabolites. It is not known if trandolapril or trandolaprilat can be usefully removed from the body by hemodialysis.

Angiotensin II could presumably serve as a specific antagonist antidote in the setting of trandolapril overdose, but angiotensin II is essentially unavailable outside of scattered research facilities. Because the hypotensive effect of trandolapril is achieved through vasodilation and effective hypovolemia, it is reasonable to treat trandolapril overdose by infusion of normal saline solution.

For convenience, patients receiving trandolapril (up to 8 mg) and verapamil (up to 240 mg) in separate tablets, administered once-a-day, may instead wish to receive trandolapril and verapamil hydrochloride extended-release tablets containing the same component doses.

Trandolapril and verapamil hydrochloride extended-release tablets should be administered with food.

Store at 20°C to 25°C (68°F to 77°F) [see USP Controlled Room Temperature].

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April 2025