What is the protocol for nicardipine (Calcium Channel Blocker) infusion titration to manage hypertension?

Nicardipine Infusion Titration Protocol for Hypertension Management

For management of hypertension with nicardipine infusion, start with 5 mg/hr IV infusion as initial dose and titrate by increasing 2.5 mg/hr every 5 minutes to a maximum of 15 mg/hr, aiming for a 10-15% reduction in blood pressure. 1

Initial Setup and Preparation

• Nicardipine must be administered as a slow continuous infusion through a central line or large peripheral vein 2
• Single dose vials (25 mg) must be diluted with 240 mL of compatible IV fluid to create a 0.1 mg/mL solution 2
• Compatible IV fluids include: Dextrose (5%), Normal Saline (0.9%), and combinations of these solutions 2
• Not compatible with Sodium Bicarbonate (5%) or Lactated Ringer's solutions 2
• Change infusion site every 12 hours if administered via peripheral vein to minimize risk of phlebitis 2, 3

Titration Protocol Based on Clinical Scenario

For Non-Thrombolytic Eligible Patients:

• Starting dose: 5 mg/hr IV infusion 1
• Titration: Increase by 2.5 mg/hr every 5 minutes until desired effect 1
• Maximum dose: 15 mg/hr 1
• Target: 10-15% reduction in blood pressure 1
• Indication: Systolic BP >220 mmHg or Diastolic BP 121-140 mmHg 1

For Thrombolytic Eligible Patients (Pre-treatment):

• Starting dose: 5 mg/hr IV infusion 1
• Titration: Increase by 2.5 mg/hr at 5-15 minute intervals 1
• Maximum dose: 15 mg/hr 1
• Target: Reduce and maintain BP below 185/110 mmHg 1
• Note: If BP cannot be maintained below 185/110 mmHg, do not administer rtPA 1

For Thrombolytic Patients (During/After Treatment):

• For Systolic BP >230 mmHg or Diastolic BP 121-140 mmHg:
  • Start at 5 mg/hr IV infusion 1
  • Titrate up by 2.5 mg/hr every 5 minutes 1
  • Maximum dose of 15 mg/hr 1
  • If BP not controlled with nicardipine, consider sodium nitroprusside 1

Monitoring Parameters

• Monitor blood pressure and heart rate continuously during titration 2
• For thrombolytic patients, check BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, and then hourly for 16 hours 1
• Assess for signs of hypotension or tachycardia 2
• If hypotension or tachycardia occurs, discontinue infusion and restart at lower dose (3-5 mg/hr) after stabilization 2

Pharmacokinetic Considerations

• Onset of action: 5-15 minutes 1
• Duration of action: 30-40 minutes after discontinuation 1
• Blood pressure begins to fall within minutes of starting infusion 2
• Reaches approximately 50% of ultimate decrease in about 45 minutes with constant infusion 2
• After discontinuation, 50% offset of action occurs in approximately 30 minutes 2

Special Considerations

• Contraindicated in patients with advanced aortic stenosis 2
• Use with caution in patients with hepatic impairment 2
• Monitor closely in patients with angina, congestive heart failure, or renal impairment 2
• Nicardipine is not a beta-blocker and provides no protection against dangers of abrupt beta-blocker withdrawal 2
• May increase cyclosporine and tacrolimus plasma levels; frequent monitoring recommended when co-administered 2

Common Adverse Effects

• Headache (13%), hypotension (5%), tachycardia (4%), and nausea/vomiting (4%) 2
• Phlebitis may occur at infusion site, especially after prolonged infusion (>14 hours) at a single site 3
• To minimize venous irritation, change infusion site every 12 hours 2

By following this protocol, nicardipine infusion can be effectively titrated to safely manage hypertension while minimizing the risk of adverse effects and optimizing patient outcomes.