Pharmacokinetics, bioavailability and ECG response of verapamil in patients with liver cirrhosis.

1 The pharmacokinetics, bioavailability and ECG response of verapamil was investigated in seven patients with liver cirrhosis and compared with six normal subjects, using stable labelled techniques whereby both the intravenous and oral dose are given simultaneously. 2 After intravenous administration, plasma concentrations were much higher in the patient group such that the total plasma clearance was reduced from a mean of 1258 ml/min in normals to 616 ml/min in the patient group (P less than 0.0025). The apparent volume of distribution nearly doubled (6.76 v 12.05 l/kg, P less than 0.025) and the terminal half-life was prolonged four fold (3.7 v 14.2 h, P less than 0.001). 3 Given orally, the peak plasma concentration was higher and occurred earlier in the liver cirrhotic patients. The absolute bioavailability more than doubled (22.0% normals v 52.3% liver cirrhotics, P less than 0.001) and apparent oral clearance was reduced to only 20% of normal (6.38 v 1.30 l/min, P less than 0.001). 4 The delta P-R interval in the patient group lagged behind the plasma concentration, in contrast to normal subjects. The maximum effect was much greater in the patients (15.4 v 41.6% increase, P less than 0.005) and persisted for a longer period of time. The slope of the plasma concentration-response curve was the same as in normals after intravenous administration. Plasma protein binding remained unchanged. 5 It is recommended that in liver cirrhotic patients the intravenous dose of verapamil be halved and the oral dose decreased by a factor of five in order to prevent untoward effects. As well as a steady-state plasma concentration will not be reached until approximately 2 days after the beginning of therapy.