What is the recommended dosing for nicardipine (calcium channel blocker) in a patient with a brain bleed to control systolic blood pressure?

From the Guidelines

For a patient with a brain bleed, nicardipine is typically initiated as a continuous IV infusion at 5 mg/hour, which can be titrated by 2.5 mg/hour every 5-15 minutes as needed, up to a maximum of 15 mg/hour. The goal is to maintain systolic blood pressure below 140-160 mmHg to reduce the risk of hematoma expansion while avoiding excessive hypotension. This recommendation is based on the most recent and highest quality study available, which provides guidance on the management of blood pressure in patients with acute ischemic stroke 1.

Key Considerations

• Close blood pressure monitoring is essential during administration, preferably with an arterial line for accurate readings.
• Once the target blood pressure is achieved and stable for at least 24 hours, the infusion can be gradually weaned while transitioning to oral antihypertensives.
• Nicardipine works by blocking L-type calcium channels in vascular smooth muscle, causing vasodilation and reducing peripheral vascular resistance.
• Patients should be monitored for potential side effects including reflex tachycardia, headache, flushing, and peripheral edema.
• Liver function should be assessed regularly as nicardipine is metabolized hepatically.

Management Approach

• The management of blood pressure during and after treatment with rtPA or other acute reperfusion therapy should aim to maintain BP at or below 180/105 mm Hg.
• If systolic BP >180–230 mm Hg or diastolic BP >105–120 mm Hg, labetalol or nicardipine can be used to lower the blood pressure.
• If BP is not controlled or diastolic BP >140 mm Hg, consider IV sodium nitroprusside.

Evidence Base

The recommendation for nicardipine dosing in patients with brain bleed is supported by guidelines from the American Heart Association/American Stroke Association 1, which emphasize the importance of careful blood pressure management in the acute phase of stroke. The use of nicardipine as a continuous IV infusion is also supported by earlier guidelines 1, which provide detailed information on the dosing and titration of nicardipine in this setting.

From the FDA Drug Label

Individualize dosage based upon the severity of hypertension and response of the patient during dosing In a drug-free patient, initiate therapy at 5 mg/hr. Increase the infusion rate by 2. 5 mg/hr to a maximum of 15 mg/hr until desired blood pressure reduction is achieved.

The recommended dosing for nicardipine in a patient with a brain bleed to control systolic blood pressure is to initiate therapy at 5 mg/hr and increase the infusion rate by 2.5 mg/hr to a maximum of 15 mg/hr until the desired blood pressure reduction is achieved.

• The infusion rate can be increased every 15 minutes for a gradual blood pressure reduction or every 5 minutes for a rapid reduction.
• If hypotension or tachycardia ensues, discontinue the infusion and restart at a low dose, such as 3 to 5 mg/hr, after stabilization 2.

From the Research

Nicardipine Dosing for Brain Bleed

• The recommended dosing for nicardipine in a patient with a brain bleed to control systolic blood pressure is typically initiated at 5 mg/hour, with adjustments made to maintain systolic blood pressure between 120 and 160 mm Hg 3.
• Factors associated with nicardipine dosing include sex, age, body weight, and initial systolic blood pressure, with men, younger patients, and those with higher initial systolic blood pressure requiring higher doses 3.
• The maximum hourly dose of nicardipine has been associated with early neurologic deterioration, with a dose of 9.1 ± 4.2 mg/hour being reported in one study 3.
• In other studies, nicardipine has been administered at doses ranging from 4 to 15 mg/hour, with a maintenance infusion of 3 to 5 mg/hr being used to control hypertension 4, 5.
• It is essential to note that the dosing of nicardipine may vary depending on the specific clinical scenario and the patient's response to treatment, and should be guided by close monitoring of blood pressure and clinical status 3, 4, 5, 6.

Considerations for Nicardipine Use

• Nicardipine has been shown to be effective in reducing blood pressure in patients with severe hypertension, including those with brain bleeds 3, 4, 6.
• The use of nicardipine in patients with brain bleeds requires careful consideration of the potential risks and benefits, including the risk of neurologic deterioration and the potential for improved outcomes with blood pressure control 3, 7.
• Nicardipine may be preferred over other antihypertensive agents in certain clinical scenarios, such as in patients with signs or symptoms suggestive of end-organ damage 6.

Clinical Evidence

• Studies have demonstrated the efficacy and safety of nicardipine in the treatment of hypertension, including in patients with brain bleeds 3, 4, 5, 6.
• The CLUE trial, a multicenter prospective randomized trial, compared the efficacy of nicardipine and labetalol in hypertensive patients with signs or symptoms suggestive of end-organ damage, and found that nicardipine was more effective in achieving target blood pressure within 30 minutes 6.