What antihypertensive medications can be given intravenously (IV) to a patient who is nil per os (NPO) for a procedure and normally takes Coreg (carvedilol), chlorthalidone, losartan, and nifedipine, with current hypertension?

Management of Severe Hypertension in NPO Patient on Multiple Antihypertensives

For a patient who is NPO for a procedure with BP 171/111 and normally takes carvedilol, chlorthalidone, losartan, and nifedipine, intravenous nicardipine or clevidipine are the preferred first-line medications due to their rapid onset, predictable dose-response relationship, and favorable safety profiles. 1

Medication Options for IV Administration

First-Line Options:

• Nicardipine:

  • Initial dose: 5 mg/h IV
  • Titration: Increase every 5 minutes by 2.5 mg/h to maximum 15 mg/h
  • Advantages: Predictable response, minimal effect on heart rate

• Clevidipine:

  • Initial dose: 1-2 mg/h IV
  • Titration: Double dose every 90 seconds initially, then adjust more gradually
  • Advantages: Ultra-short acting, rapid onset/offset, lipid emulsion 2

Alternative Options:

• Labetalol:

  • Dosing: 0.3-1.0 mg/kg IV (maximum 20 mg) slow injection every 10 min or 0.4-1.0 mg/kg/h IV infusion
  • Particularly useful for patients already on beta-blockers (like carvedilol)

• Esmolol:

  • Dosing: 0.5-1 mg/kg IV bolus followed by 50-300 μg/kg/min continuous infusion
  • Useful when beta-blockade is specifically desired

• Sodium nitroprusside:

  • Dosing: Initial 0.3-0.5 mcg/kg/min IV
  • Note: Use with caution due to risk of cyanide toxicity with prolonged use

Treatment Algorithm

1. Initial Assessment:

   • Confirm blood pressure reading (171/111 mmHg)
   • Determine if there are signs of end-organ damage (hypertensive emergency)

2. Treatment Goals:

   • Reduce BP by no more than 25% within the first hour
   • Then aim for BP <160/100 mmHg in next 2-6 hours
   • Cautiously normalize over 24-48 hours 1

3. Medication Selection Based on Patient Profile:

   • Since patient is on carvedilol (beta-blocker), nicardipine or clevidipine would be preferred to avoid excessive beta-blockade
   • If the patient has coronary disease (suggested by multiple antihypertensives), nicardipine is particularly beneficial

4. Monitoring:

   • Continuous BP monitoring during IV administration
   • Monitor every 5 minutes during initial titration
   • Consider arterial line for precise monitoring in severe cases 1

5. Transition Back to Oral Medications:

   • Resume the patient's usual medications (carvedilol, chlorthalidone, losartan, nifedipine) once oral intake is permitted
   • Overlap IV and oral therapy during transition to prevent rebound hypertension

Special Considerations

• Avoid excessive BP reduction as it can lead to organ hypoperfusion, causing stroke, myocardial infarction, or acute kidney injury 1

• Perioperative management: For patients undergoing surgery, BP levels of 180/110 mmHg or greater should be controlled prior to surgery. Intravenous infusions of sodium nitroprusside, nicardipine, and labetalol can be effective 3

• Caution with nitroprusside in patients with renal failure (relevant if the patient has kidney disease) 1

• Post-procedure hypertension is common due to increased sympathetic tone and vascular resistance. Contributing factors include pain and increased intravascular volume 3

Pitfalls to Avoid

• Avoid oral nifedipine for acute BP management (patient's usual medication) as it can cause unpredictable drops in BP

• Avoid hydralazine due to unpredictable and prolonged hypotensive effects

• Don't reduce BP too rapidly as this can lead to cerebral, cardiac, or renal hypoperfusion

• Don't withhold treatment as untreated hypertensive emergencies have a 1-year mortality rate >79% 1