What drugs increase Intracranial Pressure (ICP)?

From the Guidelines

Certain medications can increase intracranial pressure (ICP). It is recommended to avoid or use with caution the following drugs in patients with elevated ICP:

• Corticosteroids like dexamethasone, especially at high doses (more than 10 mg per day) and long durations (more than 5 days) 1
• Sedatives like midazolam and propofol, which can cause cerebral vasodilation and increase ICP 1
• Anesthetics like isoflurane, sevoflurane, and desflurane, which can also cause cerebral vasodilation 1
• Opioids like fentanyl and morphine, which can increase cerebral blood flow and ICP 1
• Vasopressors like phenylephrine, which can increase cerebral perfusion pressure and potentially worsen ICP 1

Key Considerations

• Neuromuscular blocking agents (NMBAs) like vecuronium and atracurium may have minimal effects on ICP and systemic blood pressure in most patients when administered as a single dose 1
• However, some patients may be sensitive to the vagolytic or histamine-releasing effects of NMBAs, and alternative agents should be considered if problems arise 1
• The use of certain medications, such as mannitol and barbiturates, may be effective in reducing ICP, but their efficacy and safety profiles should be carefully evaluated 1
• It is essential to carefully weigh the benefits and risks of these medications in patients with elevated ICP and to closely monitor their ICP and clinical status 1

From the FDA Drug Label

Use morphine sulfate injection with extreme caution in patients with head injury or increased intracranial pressure In the presence of head injury, intracranial lesions or a preexisting increase in intracranial pressure, the possible respiratory depressant effects of morphine sulfate injection and its potential to elevate cerebrospinal fluid pressure (resulting from vasodilation following CO2 retention) may be markedly exaggerated All volatile anesthetics may increase intracranial pressure in patients with intracranial space occupying lesions.

• Morphine may increase intracranial pressure (ICP) due to its potential to elevate cerebrospinal fluid pressure.
• Desflurane, a volatile anesthetic, may also increase ICP in patients with intracranial space occupying lesions. These drugs should be used with caution in patients with head injury or increased ICP 2 3.

From the Research

Drugs that Increase Intracranial Pressure (ICP)

• The following drugs have been reported to increase ICP:
  • Nifedipine: a calcium channel blocker that can reduce mean arterial blood pressure (ABP) and raise mean ICP 4
  • Chlorpromazine: an antipsychotic medication that can reduce mean ABP and raise mean ICP 4
  • Reserpine: an antipsychotic and antihypertensive medication that can reduce mean ABP and raise mean ICP 4
• Other drugs that may increase ICP include:
  • Opioids: can increase ICP by causing respiratory depression and increasing cerebral blood flow 5
  • Sedatives: can increase ICP by causing respiratory depression and increasing cerebral blood flow 5

Drugs that Decrease Intracranial Pressure (ICP)

• The following drugs have been reported to decrease ICP:
  • Mannitol: an osmotic diuretic that can reduce ICP by reducing cerebral edema 6, 7, 8
  • Furosemide: a loop diuretic that can reduce ICP by reducing cerebral edema 6
  • Barbiturates: such as pentobarbital, can reduce ICP by reducing cerebral metabolism and blood flow 6, 4, 8
  • Hypertonic saline: can reduce ICP by reducing cerebral edema 7, 5