From the Guidelines
Nondrowsy, fast-acting antihypertensive medications such as clevidipine, nicardipine, and hydralazine are recommended for quickly lowering blood pressure without causing sedation. These medications are preferred in various clinical scenarios, including acute aortic dissection, acute pulmonary edema, and perioperative hypertension, as outlined in 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.
Key Medications
- Clevidipine: initial dose of 1–2 mg/h, doubling every 90 s until BP approaches target, then increasing by less than double every 5–10 min; maximum dose 32 mg/h; maximum duration 72 h 1
- Nicardipine: initial dose of 5 mg/h, increasing every 5 min by 2.5 mg/h to maximum 15 mg/h 1
- Hydralazine: initial dose of 10 mg via slow IV infusion (maximum initial dose 20 mg); repeat every 4–6 h as needed 1
Clinical Considerations
It's essential to note that blood pressure should be lowered gradually to prevent organ damage, and any fast-acting medication should be used under medical supervision, especially in emergency situations. The choice of medication depends on the underlying comorbidity and the clinical scenario, as outlined in the guidelines 1.
Recent Guidelines
The 2020 International Society of Hypertension global hypertension practice guidelines recommend optimizing the current treatment regimen, including health behavior change and diuretic-based treatment, before adding additional medications 1. However, in the context of acute hypertensive emergencies, the use of fast-acting, nondrowsy medications like clevidipine, nicardipine, and hydralazine is crucial to rapidly lower blood pressure and prevent organ damage.
From the FDA Drug Label
Losartan is indicated for the treatment of hypertension in adults and pediatric patients 6 years of age and older, to lower blood pressure. Amlodipine besylate tablets is indicated for the treatment of hypertension, to lower blood pressure. Nicardipine is indicated for the treatment of hypertension.
The FDA drug label does not provide information on nondrowsy and fast-acting antihypertensive medication options.
- Losartan 2 and Amlodipine 3 are oral medications and their onset of action may not be considered fast-acting.
- Nicardipine 4 is an intravenous medication, which may be considered fast-acting, but its label does not mention nondrowsy as a characteristic.
From the Research
Nondrowsy Fast-Acting Antihypertensive Medication Options
- The following medications are considered nondrowsy and fast-acting for lowering blood pressure:
- Labetalol, esmolol, fenoldopam, nicardipine, and clevidipine are rapid-acting intravenous antihypertensive agents 5
- Amlodipine, a dihydropyridine calcium channel blocker, has good efficacy and safety, and is considered a first-line antihypertensive agent 6
- Losartan, an angiotensin II receptor blocker, has been shown to have superior tolerability compared to other antihypertensive agents, such as lisinopril and amlodipine 7
- Combination therapies, such as a triple fixed-dose combination of an angiotensin II receptor blocker, a calcium channel blocker, and a thiazide diuretic, may also be effective in lowering blood pressure 8
Mechanism of Action and Efficacy
- Calcium channel blockers, such as amlodipine, work by inhibiting the influx of calcium ions into vascular smooth muscle and cardiac muscle, thereby reducing blood pressure 9, 6
- Angiotensin II receptor blockers, such as losartan, work by blocking the action of angiotensin II, a potent vasoconstrictor, thereby reducing blood pressure 9, 7
- The efficacy of these medications in lowering blood pressure has been demonstrated in various studies, with significant reductions in systolic and diastolic blood pressure observed 5, 6, 7