What are the current recommendations for controlling hypertension in critical care, including specific medication?

From the Guidelines

The management of hypertension in critical care settings should prioritize the use of intravenous nicardipine, clevidipine, or labetalol as first-line agents to rapidly control blood pressure and prevent end-organ damage, as recommended by the most recent guidelines 1. The choice of medication depends on the specific clinical presentation and the presence of any contraindications.

• Nicardipine is a calcium channel blocker that can be initiated at a dose of 5 mg/hr and titrated by 2.5 mg/hr every 5-15 minutes, with a maximum dose of 15 mg/hr 1.
• Clevidipine is another calcium channel blocker that can be started at a dose of 1-2 mg/hr and doubled every 90 seconds until the target blood pressure is reached, with a maximum dose of 32 mg/hr 1.
• Labetalol is a combined alpha and beta-blocker that can be administered as an initial 10-20 mg bolus, followed by 20-80 mg every 10 minutes or a continuous infusion of 0.5-2 mg/min 1. Sodium nitroprusside is also an option, but its use requires caution due to the risk of cyanide toxicity with prolonged use 1. The goal of treatment is to reduce mean arterial pressure by no more than 25% within the first hour, then gradually to 160/100-110 mmHg within the next 2-6 hours, while continuously monitoring cardiac function, blood pressure, and end-organ function 1. Specific conditions, such as acute ischemic stroke, intracerebral hemorrhage, or aortic dissection, require tailored approaches to blood pressure management, with specific target blood pressure ranges and medication choices 1. For example, in acute ischemic stroke with thrombolysis eligibility, the target blood pressure is <185/110 mmHg, while in intracerebral hemorrhage, the target is to keep systolic blood pressure <140 mmHg 1. The underlying cause of hypertension should be identified and addressed simultaneously to ensure comprehensive management 1.

From the FDA Drug Label

TABLE OF CONTENTS FULL PRESCRIBING INFORMATION: CONTENTS* 1 INDICATIONS AND USAGE 1.1 Hypertension 2 DOSAGE AND ADMINISTRATION 2.1 General Information 2.3 Dosage as a Substitute for Oral Nicardipine Therapy 2.4 Dosage for Initiation of Therapy in a Drug-Free Patient 2.5 Conditions Requiring Infusion Adjustment 7.1 Antihypertensive Agents

The current recommendations for controlling hypertension in critical care include the use of nicardipine (IV) as a medication option. The dosage and administration of nicardipine (IV) are provided in the drug label, including:

• Dosage as a substitute for oral nicardipine therapy
• Dosage for initiation of therapy in a drug-free patient
• Conditions requiring infusion adjustment It is also noted that nicardipine (IV) can be used in combination with other antihypertensive agents. 2

From the Research

Current Recommendations for Controlling Hypertension in Critical Care

The current recommendations for controlling hypertension in critical care involve the use of specific medications to safely reduce blood pressure.

• Hypertensive emergencies, which are characterized by acute end-organ damage, require immediate reduction in blood pressure with a titratable, short-acting, intravenous antihypertensive agent 3, 4.
• Hypertensive urgencies, which are characterized by severe hypertension without acute end-organ damage, can be treated with oral antihypertensive agents 3, 4.

Medications for Controlling Hypertension

The following medications are commonly used to control hypertension in critical care:

• Labetalol 3, 4
• Esmolol 3, 4
• Fenoldopam 3, 4
• Nicardipine 3, 4, 5
• Clevidipine 3, 4, 5, 6
• Sodium nitroprusside, although its use is not recommended due to its toxicity 3, 4

Comparison of Nicardipine and Clevidipine

A study comparing the efficacy and safety of nicardipine and clevidipine for blood pressure control in hypertensive crisis found that:

• There was no difference between the two agents in achieving a 25% reduction in mean arterial pressure at 1 hour 5.
• Nicardipine achieved a systolic blood pressure goal of <160 mm Hg at 2-6 hours significantly more often than clevidipine 5.
• Nicardipine showed more sustained systolic blood pressure control, with a lower risk of rebound hypertension and significant cost savings compared to clevidipine 5.