What are the first-line medications for hypertensive urgency?

From the Guidelines

The first-line medication for hypertensive urgency is typically an oral antihypertensive agent, with labetalol, captopril, or amlodipine being preferred options. Labetalol can be given at 200-400 mg orally, captopril at 25-50 mg orally, or amlodipine at 5-10 mg orally. The goal is to gradually lower blood pressure over 24-48 hours, not rapidly, as sudden drops can cause organ hypoperfusion. Blood pressure should be monitored every 30-60 minutes initially. Clonidine (0.1-0.2 mg orally) is another option but may cause sedation. Avoid sublingual nifedipine as it can cause unpredictable blood pressure drops. After initial control, patients need a comprehensive workup to identify underlying causes and establish a long-term management plan. Hypertensive urgency is defined as severely elevated blood pressure (typically >180/120 mmHg) without evidence of target organ damage, distinguishing it from hypertensive emergency which requires immediate IV therapy.

Key Considerations

• The selection of an antihypertensive agent should be based on the drug’s pharmacology, pathophysiological factors underlying the patient’s hypertension, degree of progression of target organ damage, the desirable rate of BP decline, and the patient's clinical presentation 1.
• Continuous infusion of short-acting titratable antihypertensive agents is often preferable to prevent further target organ damage 1.
• Labetalol, nicardipine, and nitroprusside are commonly used IV agents for hypertensive emergencies, with labetalol being a preferred option for certain clinical presentations such as hypertensive encephalopathy and acute ischemic stroke 1.
• The administration of ACE-inhibitors, such as enalaprilat, may be used in certain cases, but must be started at a very low dose to prevent sudden decreases in BP 1.

Monitoring and Management

• Blood pressure should be monitored closely, every 30-60 minutes initially, to avoid sudden drops and ensure gradual lowering of blood pressure.
• Patients should be evaluated for underlying causes of hypertensive urgency and a long-term management plan should be established after initial control.
• The goal is to gradually lower blood pressure over 24-48 hours, not rapidly, as sudden drops can cause organ hypoperfusion.

Clinical Presentation

• Hypertensive urgency is defined as severely elevated blood pressure (typically >180/120 mmHg) without evidence of target organ damage, distinguishing it from hypertensive emergency which requires immediate IV therapy 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Captopril tablets should be taken one hour before meals. Dosage must be individualized. Hypertension - Initiation of therapy requires consideration of recent antihypertensive drug treatment, the extent of blood pressure elevation, salt restriction, and other clinical circumstances For patients with severe hypertension (e.g., accelerated or malignant hypertension), when temporary discontinuation of current antihypertensive therapy is not practical or desirable, or when prompt titration to more normotensive blood pressure levels is indicated, diuretic should be continued but other current antihypertensive medication stopped and captopril dosage promptly initiated at 25 mg bid or tid, under close medical supervision

The first-line medication for hypertensive urgency mentioned is captopril.

• The initial dose is 25 mg bid or tid.
• Diuretics may also be used in conjunction with captopril.
• Beta-blockers, such as labetalol, may also be used, but the effects are less than additive 2.
• Labetalol is indicated for the management of hypertension, and may be used alone or in combination with other antihypertensive agents 3.

From the Research

First-Line Medications for Hypertensive Urgency

The following medications are considered first-line treatments for hypertensive urgency:

• Nifedipine 4, 5, 6, 7
• Clonidine 4, 5, 6, 7
• Captopril 4, 6, 7
• Labetalol 4, 6, 7

Characteristics of First-Line Medications

These medications have the following characteristics:

• Rapid onset of action: Nifedipine and captopril have an onset of action within 0.5-1 hour 4
• Effective blood pressure lowering: All four medications can lower blood pressure effectively within a few hours of dosing 4, 5, 6, 7
• Potential for adverse effects: All four medications have been associated with adverse effects, such as hypotension and sedation 4, 5, 6, 7

Selection of First-Line Medications

The selection of a first-line medication for hypertensive urgency should be based on:

• The perceived need for urgent blood pressure control 4
• The cause of the hypertensive urgency 4
• Concomitant conditions, such as renal disease or heart failure 4