From the Guidelines
Hypertensive urgency unresponsive to amlodipine 10 mg should be managed with intravenous antihypertensive agents, such as nicardipine, clevidipine, or nitroglycerin, due to their rapid onset of action and titratability.
Key Considerations
- The choice of agent depends on the patient's clinical presentation, comorbidities, and potential contraindications, as outlined in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1.
- Nicardipine is a commonly used option, with a usual dose range of 5-15 mg/h, and can be increased by 2.5 mg/h every 5-10 minutes to achieve the target blood pressure 1.
- Clevidipine is another option, with a dose range of 1-2 mg/h, and can be doubled every 90 seconds until the target blood pressure is reached 1.
- Nitroglycerin can also be used, with a dose range of 5-200 mcg/min, and can be increased by 5 mcg/min every 5 minutes to achieve the target blood pressure 1.
Important Contraindications and Adverse Effects
- Nicardipine is contraindicated in liver failure, and can cause headache and reflex-tachycardia 1.
- Clevidipine can cause headache and reflex-tachycardia 1.
- Nitroglycerin can cause headache and reflex-tachycardia, and should be used with caution in patients with liver or kidney failure 1.
Additional Considerations
- Intra-arterial blood pressure monitoring is recommended to prevent "overshoot" and ensure accurate blood pressure control 1.
- Concomitant administration of loop diuretics may be beneficial in reducing volume overload and further lowering blood pressure 1.
From the Research
Management of Hypertensive Urgency Unresponsive to Amlodipine
- Hypertensive urgency unresponsive to amlodipine 10 mg may require alternative treatment strategies, as the current dosage may not be sufficient to control blood pressure 2.
- Increasing the dose of amlodipine to 10 mg daily has been shown to be effective in controlling hypertension without elevating serum uric acid 2.
- Combination therapy with other antihypertensive agents, such as diuretics, beta-blockers, or angiotensin-converting enzyme inhibitors, may be considered to achieve better blood pressure control 3, 4, 5.
- The addition of amlodipine to existing antihypertensive therapy, such as captopril, has been shown to be effective in reducing blood pressure in patients with moderate to severe essential hypertension 6.
- Amlodipine has been demonstrated to be well-tolerated and effective as monotherapy or in combination with other antihypertensive agents, with a useful clinical dose range of 5-10 mg 3, 4, 5.