What is the titration protocol for Cardene (nicardipine)?

Nicardipine (Cardene) Titration Protocol

For hypertensive emergencies, nicardipine should be initiated at 5 mg/h, increasing every 5 minutes by 2.5 mg/h to a maximum of 15 mg/h. 1

Intravenous Nicardipine Administration Guidelines

Initial Dosing and Titration

• Start with 5 mg/h as continuous IV infusion 1
• Increase by 2.5 mg/h increments every 5 minutes until desired blood pressure is reached 1
• Maximum recommended dose is 15 mg/h 1
• Once target blood pressure is achieved, the infusion can be maintained at that rate 2

Monitoring Requirements

• Continuous blood pressure monitoring is essential during titration 1
• Monitor heart rate to avoid tachycardia (a common side effect) 2
• For hypertensive emergencies, intensive care unit admission is recommended for continuous monitoring 1

Blood Pressure Reduction Targets

• For patients without compelling conditions: reduce systolic BP by no more than 25% within the first hour 1
• If stable after initial reduction, aim for BP of 160/100 mmHg within the next 2-6 hours 1
• Then cautiously reduce to normal over the following 24-48 hours 1
• For compelling conditions (aortic dissection, severe preeclampsia/eclampsia, pheochromocytoma crisis): reduce systolic BP to less than 140 mmHg during the first hour 1

Preparation and Administration

• Dilute single-dose vials (25 mg) with 240 mL of compatible IV fluid to achieve concentration of 0.1 mg/mL 2
• Compatible IV fluids include: Dextrose (5%) Injection, Sodium Chloride (0.9%) Injection, and various combinations 2
• Not compatible with Sodium Bicarbonate (5%) Injection or Lactated Ringer's Injection 2
• Administer via slow continuous infusion through a central line or large peripheral vein 2
• Change infusion site every 12 hours if administered via peripheral vein 2

Special Considerations

• Onset of action: 5-15 minutes 1
• Duration of action: 30-40 minutes 1
• Contraindicated in patients with advanced aortic stenosis 1
• No dose adjustment needed for elderly patients 1
• Use with caution in patients with liver failure 1

Common Side Effects

• Headache and reflex tachycardia are the most common side effects 1
• Flushing, dizziness, and peripheral edema may also occur 1

Transitioning to Oral Therapy

• When transitioning from IV to oral nicardipine, the typical oral dosing is 20-40 mg three times daily 3
• Allow at least 3 days before increasing the oral dose to ensure achievement of steady-state plasma drug concentrations 3
• For hypertension management, oral dosing should be individually adjusted according to blood pressure response 3

Clinical Pearls

• Nicardipine is a dihydropyridine calcium channel blocker with potent vasodilatory effects 1
• It has minimal effects on cardiac conduction compared to non-dihydropyridine calcium channel blockers like verapamil and diltiazem 1
• The ability to titrate IV nicardipine to individual patient tolerance makes it particularly useful in critically ill patients 4
• Blood pressure reduction correlates well with plasma levels, demonstrating linear kinetics 5