What alternative to Losartan (losartan) can be given intravenously (IV) with a heart rate of 68 beats per minute (bpm) and no fenoldopam?

From the Guidelines

Labetalol IV is the recommended alternative to losartan for immediate blood pressure control in patients with a heart rate of 68 bpm and no fenoldopam available, as it is a first-line treatment for various hypertensive emergencies, including malignant hypertension, hypertensive encephalopathy, and acute ischemic stroke 1.

Key Considerations

• The patient's heart rate is within a relatively normal range, which is important when considering the use of beta-blockers like labetalol.
• The absence of fenoldopam, a dopamine receptor agonist, does not impact the choice of labetalol as an alternative.
• Labetalol can be administered as a 20 mg IV bolus initially, followed by repeated doses of 20-80 mg every 10 minutes as needed, or as a continuous infusion at 1-2 mg/min.

Alternative Options

• Nicardipine IV can be considered as an alternative, given as a continuous infusion starting at 5 mg/hour, titrated by 2.5 mg/hour every 5-15 minutes up to 15 mg/hour 1.
• Other options like nitroprusside, urapidil, and esmolol may also be considered based on the patient's specific condition and comorbidities.

Mechanism of Action

• Labetalol blocks both alpha and beta receptors, which helps to reduce blood pressure by decreasing cardiac output and peripheral resistance.
• Nicardipine, on the other hand, is a calcium channel blocker that causes arterial vasodilation, leading to a decrease in blood pressure.

Monitoring and Titration

• It is essential to monitor blood pressure and heart rate closely during administration of any of these alternatives to ensure effective blood pressure control and minimize potential side effects.
• The choice of medication and dosing regimen should be tailored to the individual patient's needs, taking into account their specific condition, comorbidities, and response to treatment.

From the FDA Drug Label

NICARDIPINE HYDROCHLORIDE injection, for intravenous use ... Nicardipine hydrochloride injection is a calcium channel blocker indicated for the short-term treatment of hypertension when oral therapy is not feasible. ... In a drug-free patient, initiate therapy at 5 mg/hr. Increase the infusion rate by 2. 5 mg/hr to a maximum of 15 mg/hr until desired blood pressure reduction is achieved.

Alternative to Losartan: Nicardipine can be given intravenously (IV) as an alternative to Losartan for the short-term treatment of hypertension. Key Considerations:

• The patient's heart rate of 68 bpm is not a contraindication for nicardipine use.
• The absence of fenoldopam does not affect the use of nicardipine.
• Initiate therapy at 5 mg/hr and adjust as needed to achieve desired blood pressure reduction 2

From the Research

Alternative to Losartan

Given the patient's heart rate of 68 beats per minute (bpm) and the absence of fenoldopam, alternative intravenous (IV) options can be considered for managing hypertension.

• Nicardipine: A water-soluble calcium channel antagonist with predominantly vasodilatory actions, nicardipine can be administered IV for rapid control of blood pressure 3, 4. It has been shown to be effective in the short-term treatment of hypertension, including postoperative hypertension, and can be easily titrated to individual patient tolerance.
• Clevidipine: Another dihydropyridine calcium channel antagonist, clevidipine is available as a lipid emulsion for IV infusion and is approved for the reduction of blood pressure when oral therapy is not feasible or desirable 5. It has a rapid onset and short duration of action, allowing for easy titration and predictable blood pressure control. Clevidipine has been shown to be effective in treating acute preoperative and postoperative hypertension in adult cardiac surgery patients.

Comparison of Alternatives

Both nicardipine and clevidipine have been compared to other antihypertensive agents, including sodium nitroprusside and nitroglycerin, and have been found to be effective alternatives for managing acute hypertension 5, 6. The choice between these alternatives may depend on individual patient factors, such as the presence of certain comorbidities or concomitant medications.

Considerations for Use

When considering the use of nicardipine or clevidipine as an alternative to losartan, it is essential to take into account the patient's individual characteristics, such as heart rate and blood pressure, as well as any potential contraindications or interactions with other medications 3, 5. Close monitoring of blood pressure and heart rate is necessary to ensure safe and effective use of these agents.