From the Guidelines
For managing blood pressure in the inpatient setting, I recommend starting with intravenous labetalol, as it is a preferred first-line treatment for various hypertensive emergencies, including malignant hypertension, hypertensive encephalopathy, and acute ischemic stroke, as indicated in the 2019 European Heart Journal study 1.
Key Considerations
- Labetalol can be administered as a 10-20 mg IV bolus, which can be repeated or doubled every 10 minutes up to 300 mg total.
- In hypertensive emergencies with end-organ damage, nicardipine infusion at 5 mg/hour, titrated by 2.5 mg/hour every 5-15 minutes up to 15 mg/hour, or clevidipine starting at 1-2 mg/hour and titrated every 90 seconds, are excellent alternatives, as suggested by the 2018 Circulation study 1.
- For ongoing BP management, transition to oral medications as soon as clinically appropriate, with first-line oral options including ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics.
Medication Selection
- The choice of medication should be tailored to the patient's comorbidities, with ACE inhibitors or ARBs preferred in diabetes or kidney disease, and calcium channel blockers or thiazides in Black patients, as recommended by the 2018 Circulation study 1.
- Beta-blockers like metoprolol are particularly useful in patients with coronary artery disease or heart failure.
Monitoring and Adjustments
- Regular monitoring of blood pressure, electrolytes, and kidney function is essential during medication adjustments, as emphasized by the 2024 Annals of Internal Medicine study 1.
- The 2024 Annals of Internal Medicine study 1 highlights the importance of systematic identification of guidelines on elevated BP management in the hospital, which can help inform treatment decisions and improve patient outcomes.
From the FDA Drug Label
1.1 Hypertension Lisinopril tablets USP are indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure. Nicardipine injection is used to treat high blood pressure and control angina (chest pain) in certain patients.
- Inpatient blood pressure medications include:
From the Research
Inpatient Blood Pressure Medications
The following medications are used to manage hypertension in the inpatient setting:
- Nicardipine 4, 5, 6
- Labetalol 5, 7, 4, 6
- Hydralazine 7, 4
- Nitroprusside 4
- Fenoldopam 4
- Nitroglycerin 4
- Enalaprilat 4
- Esmolol 4
- Phentolamine 4
- Clevidipine 4
Characteristics of Inpatient Blood Pressure Medications
These medications are often administered intravenously and are characterized by a short onset and offset of action, allowing for predictable responses during dosage adjustments to reach blood pressure goals 4. The selection of a specific agent should be based on the agent's pharmacology and patient-specific factors, such as comorbidity and the presence of end-organ damage 4.
Comparison of Inpatient Blood Pressure Medications
Studies have compared the effectiveness of different medications, such as nicardipine and labetalol, in managing hypertension in the inpatient setting 5, 6. These studies have found that nicardipine may be more effective than labetalol in achieving blood pressure targets, with fewer adverse effects 5. However, the choice of medication ultimately depends on individual patient characteristics and the specific clinical scenario 4.