What medications are recommended for managing hypertensive urgency?

Management of Hypertensive Urgency

For hypertensive urgency, oral antihypertensive medications with reinstitution or intensification of therapy is recommended, with blood pressure reduction by no more than 25% within the first hour, then to 160/100 mmHg within 2-6 hours, and gradually to normal over 24-48 hours. 1

Definition and Distinction

Hypertensive urgency is characterized by:

• Severe BP elevation (>180/120 mmHg)
• Absence of acute or impending target organ damage
• Patient is otherwise stable

This differs from hypertensive emergency, which involves evidence of new or worsening target organ damage and requires immediate parenteral therapy in an ICU setting.

Treatment Algorithm for Hypertensive Urgency

Step 1: Assessment

• Confirm BP readings and absence of target organ damage
• Determine if patient has withdrawn from or is non-compliant with previous antihypertensive therapy
• Check for clinical or laboratory evidence of acute target organ damage

Step 2: Management Approach

• Setting: Outpatient management is appropriate (no need for emergency department referral or hospitalization) 1
• Goal: Reduce BP gradually over 24-48 hours
• Method: Oral antihypertensive medications

Step 3: Medication Selection

Based on the most recent guidelines, the following oral agents are effective for hypertensive urgency:

1. Oral antihypertensive agents:

   • Reinstitution of previously prescribed medications if non-compliance was the issue
   • Intensification of current regimen if inadequate control is the issue

2. Specific oral medications that have been shown to be effective:

   • Captopril (ACE inhibitor)
   • Labetalol (combined alpha and beta blocker)
   • Clonidine (central alpha-2 agonist)
   • Oral calcium channel blockers

Important Cautions

• Avoid rapid BP reduction: This can lead to cerebral, renal, or coronary ischemia 1
• Short-acting nifedipine is contraindicated: No longer considered acceptable for initial treatment of hypertensive urgencies due to risk of precipitous drops in BP 1
• Monitor closely: Even though hospitalization is not required, close follow-up is essential

Special Considerations

• For patients with severe hypertension who cannot temporarily discontinue current therapy, captopril can be initiated at 25 mg bid or tid under close medical supervision 2
• For elderly patients or those with volume depletion, lower initial doses may be appropriate to avoid excessive BP reduction

Follow-up

• Arrange follow-up within 24-48 hours to ensure adequate BP control
• Address underlying causes of hypertension and medication adherence
• Adjust long-term antihypertensive regimen as needed

By following this structured approach to hypertensive urgency, clinicians can effectively manage these patients in the outpatient setting while avoiding the risks associated with overly aggressive BP reduction.