What medications are used to treat hypertensive urgency?

Medications for Treating Hypertensive Urgency

For hypertensive urgency, labetalol is the preferred first-line medication due to its combined alpha and beta-blocking properties, predictable response, and safety profile. 1

Definition and Distinction

• Hypertensive urgency is defined as severe blood pressure elevation (typically >180/120 mmHg) without evidence of acute target organ damage 1
• This differs from hypertensive emergency, which involves the same BP elevation but with evidence of new or worsening target organ damage 1

First-Line Medications

Labetalol (IV)

• Dosing: Initial 0.3-1.0 mg/kg dose (maximum 20 mg) as slow IV injection every 10 min or 0.4-1.0 mg/kg/h IV infusion up to 3 mg/kg/h 1
• Advantages: Combined alpha1 and nonselective beta-receptor antagonist providing smooth BP reduction without increasing heart rate 2
• Efficacy: Studies show effective BP reduction with 18 of 20 patients responding to treatment, with most requiring only 20-60 mg total dose 2
• Contraindications: Reactive airways disease, COPD, heart failure, second or third-degree heart block, bradycardia 1

Nicardipine (IV)

• Dosing: Initial 5 mg/h, increasing every 5 min by 2.5 mg/h to maximum 15 mg/h 1
• Advantages: Calcium channel blocker with potent arteriolar vasodilation and minimal direct myocardial depression 3
• Considerations: May cause headache and reflex tachycardia 1

Alternative Medications

Clevidipine (IV)

• Dosing: Initial 1-2 mg/h, doubling every 90 seconds until BP approaches target 1
• Advantages: Ultra-short acting calcium channel blocker with rapid onset and offset 1
• Maximum dose: 32 mg/h; maximum duration 72 hours 1

Esmolol (IV)

• Dosing: Loading dose 500-1000 mcg/kg/min over 1 min followed by 50 mcg/kg/min infusion 1
• Advantages: Very short-acting beta-1 selective blocker with rapid onset (1-2 min) and short duration (10-30 min) 1
• Contraindications: Concurrent beta-blocker therapy, bradycardia, decompensated heart failure 1

Fenoldopam (IV)

• Dosing: Initial 0.1-0.3 mcg/kg/min; may be increased in increments of 0.05-0.1 mcg/kg/min every 15 min 1
• Advantages: Dopamine-receptor1 selective agonist, particularly useful in patients with renal impairment 1
• Contraindications: Increased intraocular pressure, glaucoma, sulfite allergy 1

Blood Pressure Reduction Goals

• For hypertensive urgency (without compelling conditions), SBP should be reduced by no more than 25% within the first hour 1
• Then, if stable, to 160/100 mmHg within the next 2-6 hours 1
• Finally, cautiously to normal during the following 24-48 hours 1

Special Considerations

• Oral medications: While IV medications are preferred for emergencies, hypertensive urgencies can often be managed with oral agents 3
• Monitoring: Regular BP monitoring is essential during treatment to prevent excessive BP reduction 4
• Avoid rapid BP reduction: Excessive lowering can lead to organ hypoperfusion, particularly cerebral hypoperfusion 1, 4

Medication Selection Based on Comorbidities

• Acute coronary syndromes: Esmolol, labetalol, nicardipine, or nitroglycerin 1
• Acute pulmonary edema: Clevidipine, nitroglycerin, nitroprusside 1
• Acute renal failure: Clevidipine, fenoldopam, nicardipine 1
• Catecholamine excess states: Clevidipine, nicardipine, phentolamine 1
• Eclampsia/preeclampsia: Hydralazine, labetalol, nicardipine 1

Common Pitfalls to Avoid

• Excessive BP reduction: Avoid reducing BP too rapidly or excessively as it can lead to organ hypoperfusion 1
• Inappropriate medication selection: Consider patient comorbidities when selecting antihypertensive agents 1
• Inadequate monitoring: Close monitoring of BP response is essential during treatment 4
• Failure to identify underlying cause: Address the underlying cause of hypertensive urgency when possible 4