What is the protocol for titrating a nicardipine (Calcium Channel Blocker) drip for acute hypertension?

Nicardipine Drip Titration Protocol for Acute Hypertension

For acute hypertension management, nicardipine should be initiated at 5 mg/hr IV infusion and titrated by increasing 2.5 mg/hr every 5-15 minutes to a maximum of 15 mg/hr until the desired blood pressure is achieved. 1, 2

Initial Setup and Administration

• Nicardipine must be administered as a slow continuous infusion through a central line or large peripheral vein 2
• For single-dose vials: Dilute 25 mg in 240 mL of compatible IV fluid (D5W, NS, etc.) to achieve a concentration of 0.1 mg/mL 2
• Flexible containers (premixed) do not require dilution 2
• Change infusion site every 12 hours if administered via peripheral vein to minimize risk of phlebitis 2

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 5-15 minutes 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: If systolic BP >185 mmHg or diastolic BP >110 mmHg, start at 5 mg/hr 1
• During/after treatment: Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, and then every hour for 16 hours 1
• For systolic BP >230 mmHg or diastolic BP 121-140 mmHg: Start at 5 mg/hr, titrate up by 2.5 mg/hr every 5 minutes to maximum of 15 mg/hr 1
• For systolic BP 180-230 mmHg or diastolic BP 105-120 mmHg: Consider labetalol as first-line; nicardipine is an alternative 1

Monitoring and Adjustment

• For gradual BP reduction: increase dose every 15 minutes 2
• For more rapid BP reduction: increase dose every 5 minutes 2
• Continuous BP monitoring is essential during titration 1
• Heart rate typically increases by about 10 beats/minute during infusion 3
• Onset of action is 5-15 minutes with duration of 30-40 minutes after stopping infusion 1

Special Considerations

• Hypotension or tachycardia: Discontinue infusion immediately. When BP and heart rate stabilize, restart at lower dose (3-5 mg/hr) and titrate slowly 2
• Impaired cardiac, hepatic or renal function: Monitor closely during titration and use lower doses 2
• Pregnancy/pre-eclampsia: Nicardipine is considered safe and effective; target BP <160/105 mmHg 1
• Acute aortic dissection: Consider beta-blockers first; nicardipine can be added if needed 1
• Acute pulmonary edema: Nicardipine is effective but nitrates may be preferred 1

Transitioning to Oral Therapy

• When switching to oral antihypertensives, initiate oral therapy upon discontinuation of nicardipine infusion 2
• If transitioning to oral nicardipine capsules, administer the first dose 1 hour prior to stopping the infusion 2

Advantages of Nicardipine

• Requires fewer dose adjustments compared to sodium nitroprusside (5.7 vs 8.8 adjustments per day) 4
• Fewer additional medications needed to maintain BP control 4
• Easily titratable with short duration of action 5
• Less negative inotropic effect and reflex tachycardia compared to nifedipine 3

Common Pitfalls to Avoid

• Do not use small veins (dorsum of hand/wrist) to avoid thrombosis and phlebitis 2
• Avoid intraarterial administration or extravasation 2
• Not compatible with Sodium Bicarbonate (5%) Injection or Lactated Ringer's Injection 2
• Monitor for headache and reflex tachycardia as common side effects 1, 3
• Phlebitis may develop after prolonged infusion (>14 hours) at a single site 3