What is the best PRN (pro re nata, as needed) intravenous (IV) antihypertensive medication for use in a hospital setting?

From the Guidelines

Labetalol is the most recommended PRN IV antihypertensive medication for hospital use due to its favorable safety profile and predictable effects. The typical dosing starts at 10-20 mg IV push over 2 minutes, which can be repeated or doubled every 10 minutes up to a maximum of 300 mg total dose. Alternatively, it can be administered as a continuous infusion at 1-2 mg/min after the initial bolus. Labetalol works through dual alpha and beta-adrenergic blockade, providing smooth blood pressure reduction without precipitous drops or reflex tachycardia. It has a rapid onset (within 5 minutes) and moderate duration (3-6 hours), making it ideal for acute hypertension management 1.

When administering labetalol, monitor blood pressure every 5-10 minutes initially, then every 15-30 minutes once stabilized. Be cautious in patients with asthma, COPD, heart failure, or heart block as beta-blockade may exacerbate these conditions. For patients with these contraindications, hydralazine (5-10 mg IV) or nicardipine infusion (5 mg/hour, titrated by 2.5 mg/hour every 5-15 minutes) may be better alternatives.

Some key points to consider when choosing an antihypertensive medication include:

• The patient's underlying medical conditions, such as heart failure or asthma
• The severity of the hypertension
• The potential for adverse effects, such as reflex tachycardia or bronchoconstriction
• The need for rapid blood pressure reduction versus the risk of precipitous drops in blood pressure. According to the most recent guidelines, nicardipine may be better than labetalol in achieving the short-term BP target 1. However, labetalol remains a popular choice due to its ease of use and predictable effects.

Other options, such as clevidipine, fenoldopam, and nitroglycerine, may also be considered in specific situations, such as patients with certain contraindications or those who require more rapid blood pressure reduction 1. Ultimately, the choice of antihypertensive medication will depend on the individual patient's needs and the clinical judgment of the healthcare provider.

From the FDA Drug Label

For intravenous use: Cleviprex is intended for intravenous use. Titrate Cleviprex to achieve the desired blood pressure reduction. Individualize dosage depending on the blood pressure response of the patient and the goal blood pressure. Initial dose: Initiate intravenous infusion of Cleviprex at 1- 2 mg/hour. Dose titration: Double the dose at short (90 second) intervals initially. As the blood pressure approaches goal, increase the dose by less than doubling and lengthen the time between dose adjustments to every 5-10 minutes.

The best PRN IV antihypertensive for in-hospital use is clevidipine (IV), as it allows for rapid titration and individualized dosage based on patient response, with an initial dose of 1-2 mg/hour and dose titration at short intervals 2.

• Key benefits of clevidipine include:
  • Rapid onset of action
  • Easy dose titration
  • Individualized dosage based on patient response Note that nicardipine (IV) label does not provide sufficient information for PRN use 3.

From the Research

PRN IV Antihypertensive Medications

• The choice of PRN (pro re nata, as needed) intravenous (IV) antihypertensive medication in a hospital setting depends on various factors, including the patient's condition, the severity of hypertension, and the potential side effects of the medication.
• Several studies have compared the efficacy and safety of different IV antihypertensive medications, including clevidipine, nicardipine, sodium nitroprusside, and nitroglycerin 4, 5, 6, 7, 8.

Efficacy and Safety of Clevidipine

• Clevidipine, a third-generation dihydropyridine calcium channel blocker, has been shown to be effective in reducing blood pressure in patients with acute hypertension, including those with perioperative and postoperative hypertension 4, 5.
• Clevidipine has a rapid onset and short duration of action, making it easily titratable for predictable blood pressure control 4.
• Compared to nicardipine, clevidipine has been shown to have a faster time to target blood pressure range, although the percentage of time in blood pressure range was similar between the two medications 6.

Comparison with Other Medications

• Nicardipine, a water-soluble calcium channel antagonist, has been used for the short-term treatment of hypertension and has been shown to be effective in reducing blood pressure in patients with severe or postoperative hypertension 7.
• Sodium nitroprusside and nitroglycerin are also commonly used IV antihypertensive medications, although they may have more potential side effects and difficulties in use compared to newer agents like clevidipine and nicardipine 8.
• The choice of medication ultimately depends on the individual patient's needs and the clinical setting, with consideration of factors such as efficacy, safety, and ease of use 4, 5, 6, 7, 8.