What are the medications and doses used to manage acute hypertension?

Medications for Managing Acute Hypertension

The first-line intravenous medications for managing hypertensive emergencies are nicardipine, clevidipine, labetalol, esmolol, and sodium nitroprusside, with selection based on specific patient conditions and comorbidities. 1

First-Line IV Medications and Dosing

Calcium Channel Blockers

• Nicardipine

  • Initial dose: 5 mg/h IV
  • Titration: Increase by 2.5 mg/h every 5 minutes
  • Maximum dose: 15 mg/h 1
  • Administration: Dilute 25 mg in 240 mL of compatible IV fluid (0.1 mg/mL) 2
  • Compatible with: Dextrose 5%, Normal Saline 0.9%, combinations 2

• Clevidipine

  • Initial dose: 1-2 mg/h IV
  • Titration: Double dose every 90 seconds initially, then adjust more gradually
  • Advantages: Rapid onset and offset of action 1

Beta-Blockers and Combined Alpha/Beta Blockers

• Labetalol

  • Bolus: 20-80 mg IV every 10 minutes
  • Infusion: 0.3-1.0 mg/kg IV (maximum 20 mg) or 0.4-1.0 mg/kg/h continuous infusion
  • Onset: 5-10 minutes
  • Duration: 3-6 hours 3, 1

• Esmolol

  • Bolus: 0.5-1 mg/kg IV
  • Infusion: 50-300 μg/kg/min
  • Onset: 1-2 minutes
  • Duration: 10-30 minutes
  • Particularly useful for aortic dissection and perioperative hypertension 3, 1

Vasodilators

• Sodium Nitroprusside

  • Dose: 0.25-10 μg/kg/min as IV infusion
  • Onset: Immediate
  • Duration: 1-2 minutes
  • Caution: Risk of cyanide toxicity with prolonged use or renal dysfunction 3, 1

• Nitroglycerin

  • Dose: 5-100 μg/min as IV infusion
  • Onset: 2-5 minutes
  • Duration: 5-10 minutes
  • Best for hypertension with coronary ischemia 3

• Fenoldopam

  • Dose: 0.1-0.3 μg/kg/min IV infusion
  • Onset: 5 minutes
  • Duration: 30 minutes
  • Useful in most hypertensive emergencies; use with caution in glaucoma 3

• Hydralazine

  • IV: 10-20 mg IV
  • IM: 10-40 mg IM
  • Onset: 10-20 min (IV), 20-30 min (IM)
  • Duration: 1-4 h (IV), 4-6 h (IM)
  • Particularly indicated for eclampsia 3

ACE Inhibitors

• Enalaprilat
  • Dose: 1.25-5 mg every 6 hours IV
  • Onset: 15-30 minutes
  • Duration: 6-12 hours
  • Particularly useful for acute left ventricular failure 3
  • For patients with renal impairment (creatinine clearance ≤30 mL/min): initial dose 0.625 mg 4

Medication Selection Based on Specific Conditions

Aortic Dissection

• Target BP: <120 mmHg systolic within the first hour 1
• Preferred agents: Esmolol, labetalol (beta-blockade is essential) 1

Acute Coronary Syndromes

• Target BP: <140 mmHg systolic immediately 1
• Preferred agents: Nitroglycerin, esmolol, labetalol, or nicardipine 1

Eclampsia/Preeclampsia

• Target BP: <140 mmHg systolic within the first hour 1
• Preferred agents: Hydralazine, labetalol, or nicardipine
• Add: Magnesium sulfate for seizure prophylaxis 1

Acute Stroke

• Ischemic stroke with BP >220/120 mmHg: Reduce mean arterial pressure by 15% within the first hour
• Hemorrhagic stroke with BP >180 mmHg: Target 130-180 mmHg systolic immediately 1

Pheochromocytoma Crisis

• Preferred agent: Phentolamine 5-15 mg IV bolus
• Alternative: Urapidil (avoids paradoxical BP elevation that can occur with labetalol) 3, 1

Oral Medications for Hypertensive Urgencies

When transitioning from IV to oral therapy or for hypertensive urgencies without end-organ damage:

• Captopril: First-line oral option 1
• Labetalol: Oral formulation effective for urgencies 1
• Amlodipine: Effective for transition to oral therapy 1
• Clonidine: Useful for hypertensive urgencies 1

Important Considerations and Cautions

• Avoid excessive BP reduction (>25% in the first hour) to prevent organ hypoperfusion 1
• Continuous monitoring of BP, heart rate, and oxygen saturation is essential 1
• Avoid sodium nitroprusside when possible due to cyanide toxicity risk 1, 5
• Avoid nifedipine, nitroglycerin and hydralazine as first-line therapies due to significant toxicities 5
• Avoid nitrates with PDE-5 inhibitors due to risk of profound hypotension 1
• Change peripheral IV sites every 12 hours when administering nicardipine 2

When managing acute hypertension, medication selection should be based on the specific clinical scenario, comorbidities, and target organ involvement to optimize outcomes and minimize adverse effects.