What additional medication can be given to a patient with hypertension who is already receiving hydralazine (apresoline) intravenous (IV) push?

From the Guidelines

For a patient already on hydralazine IV push who remains hypertensive, labetalol is an excellent alternative medication to further lower blood pressure. Administer labetalol 10-20 mg IV push over 2 minutes, as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. This can be repeated every 10 minutes, doubling the dose up to 80 mg per dose, with a maximum total dose of 300 mg. Labetalol is particularly effective because it's both an alpha and beta-blocker, providing rapid and potent blood pressure reduction. It has a quick onset of action (within 2-5 minutes) and a duration of about 2-4 hours. Some key points to consider when administering labetalol include:

• Monitoring blood pressure closely after administration
• Considering starting a continuous IV infusion of nicardipine or clevidipine as the next step if the patient doesn't respond adequately to labetalol
• Being cautious in patients with severe bradycardia, heart block, or acute heart failure, as labetalol can exacerbate these conditions
• Ensuring the patient isn't asthmatic, as beta-blockers can trigger bronchospasm. The dosage and administration of labetalol are supported by the guidelines, which provide a comprehensive approach to managing high blood pressure in adults 1.

From the FDA Drug Label

Since nicardipine hydrochloride injection may be administered to patients already being treated with other medications, including other antihypertensive agents, careful monitoring of these patients is necessary to detect and to treat promptly any undesired effects from concomitant administration. In most patients, nicardipine hydrochloride injection can safely be used concomitantly with beta-blockers. However, monitor response carefully when combining nicardipine hydrochloride injection with a beta-blocker in the treatment of congestive heart failure patients

Labetalol is a beta-blocker, and nicardipine can be safely used concomitantly with beta-blockers in most patients.

• Nicardipine (IV) can be given to a patient with hypertension who is already receiving hydralazine (IV), with careful monitoring.
• Monitor the patient's response carefully when combining nicardipine with hydralazine 2.

From the Research

Additional Medication for Hypertension

When a patient is already receiving hydralazine (apresoline) intravenous (IV) push for hypertension, additional medication can be considered to enhance blood pressure control.

• Labetalol is a potential option, as it has been compared to hydralazine in several studies 3, 4, 5, 6.
• Enalaprilat and metoprolol are also mentioned as alternatives in the context of IV antihypertensive therapy 4.
• The choice of additional medication should be based on the patient's specific condition, medical history, and the severity of their hypertension.

Considerations for Additional Medication

When selecting an additional medication, consider the following factors:

• The patient's current blood pressure readings and target blood pressure range.
• The potential for adverse effects, such as those observed with hydralazine 7 or labetalol 3, 5.
• The need for close monitoring of blood pressure and potential adjustments to the medication regimen.
• The importance of educating healthcare providers about the appropriate use of PRN antihypertensive medication in the hospital setting 6.

Potential Outcomes with Additional Medication

The use of additional medication, such as labetalol, may result in:

• Improved blood pressure control, as seen in studies comparing labetalol to hydralazine 3, 5.
• A reduction in the number of doses required to achieve target blood pressure, as observed with hydralazine 3.
• Potential adverse effects, such as those associated with labetalol or hydralazine 3, 7, 5.