From the Guidelines
For inpatient antihypertensive treatment, start with intravenous labetalol or hydralazine for acute management, as recommended by the most recent guidelines 1. The management of elevated blood pressure in the inpatient setting is crucial to prevent target organ damage and improve patient outcomes.
Key Considerations
- The benefits of intensive inpatient antihypertensive treatment have not been demonstrated, and there are no randomized trials of inpatient blood pressure management 1.
- Observational studies suggest that receipt of more intensive blood pressure treatment is associated with worse outcomes, including higher rates of acute kidney injury, stroke, and myocardial injury 1.
- The choice of antihypertensive medication should be based on the patient's underlying medical conditions, potential side effects, and the need for rapid blood pressure control.
Recommended Antihypertensive Medications
- For acute management, intravenous labetalol or hydralazine can be used, with labetalol 10-20 mg IV bolus repeated every 10-15 minutes as needed, up to 300 mg total, or hydralazine 10-20 mg IV every 4-6 hours as needed.
- For ongoing management, oral medications such as:
- ACE inhibitor (e.g., lisinopril 10-40 mg daily)
- Calcium channel blocker (e.g., amlodipine 5-10 mg daily)
- Beta-blocker (e.g., metoprolol 25-100 mg twice daily) can be used.
- Adjust dosages based on blood pressure response and patient tolerance, and monitor blood pressure frequently, aiming for a target of <140/90 mmHg for most patients.
Additional Considerations
- Consider underlying causes of hypertension and address them if possible.
- Ensure proper fluid balance and electrolyte management.
- Discontinue or modify medications that may contribute to hypertension.
- The combination of different drug classes targets multiple pathways of blood pressure regulation for more effective control, as supported by recent guidelines 1.
From the FDA Drug Label
INDICATIONS & USAGE 1. 1 Hypertension Lisinopril tablets USP are indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure. Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits Lisinopril tablets USP may be administered alone or with other antihypertensive agents [see Clinical Studies (14.1)].
Antihypertensives used for inpatients include:
- Lisinopril, which can be administered alone or with other antihypertensive agents
- Other antihypertensive drugs from a variety of pharmacologic classes, as they have been shown to reduce cardiovascular morbidity and mortality 2
From the Research
Antihypertensives Used for Inpatients
The following antihypertensives are used for inpatients:
- Labetalol 3
- Esmolol 3
- Fenoldopam 3, 4
- Nicardipine 3
- Sodium nitroprusside 3, 5
- Clevidipine 3
- Hydralazine 4, 5
- Metoprolol 4
- Enalaprilat 4
- Nifedipine 3
- Nitroglycerin 3
Administration and Usage
These antihypertensives can be administered:
- Intravenously (IV) for rapid blood pressure reduction 3, 4, 5
- Orally for less severe cases or for maintenance therapy 6, 7
- As-needed or episodically for blood pressure control 4
Considerations and Precautions
When using antihypertensives for inpatients:
- Sodium nitroprusside is extremely toxic and its use should be avoided 3
- Nifedipine, nitroglycerin, and hydralazine are associated with significant toxicities and/or adverse effects and should not be considered first-line therapies 3
- IV antihypertensives may result in unpredictable blood pressure reduction and cardiovascular events 5
- Routine use of IV antihypertensives in hospitalized non-cardiac patients may prolong inpatient stay without benefits and should be avoided 7