What are the intravenous (IV) hypertension medications used in End-Stage Renal Disease (ESRD)?

From the Guidelines

Intravenous antihypertensive medications for patients with end-stage renal disease (ESRD) should be selected carefully due to altered drug clearance, with first-line IV options including labetalol, nicardipine, or clevidipine, as recommended by the most recent guidelines 1.

Key Considerations

• The choice of medication should consider the patient's specific hemodynamic status, comorbidities, and dialyzability of the drug.
• Dosing adjustments are essential as ESRD patients have impaired drug elimination.
• Blood pressure targets should generally aim for <140/90 mmHg, with careful monitoring for orthostatic hypotension.

Recommended Medications

• Labetalol: 10-20 mg bolus, may repeat every 10 minutes, maximum 300 mg.
• Nicardipine: infusion starting at 5 mg/hour, titrating by 2.5 mg/hour every 5-15 minutes, maximum 15 mg/hour.
• Clevidipine: 1-2 mg/hour initially, doubling every 90 seconds as needed, maximum 32 mg/hour.

Medications to Avoid

• Nitroprusside: due to thiocyanate accumulation risks in ESRD patients.

Additional Considerations

• Hydralazine (10-20 mg IV every 4-6 hours) is also useful but requires careful monitoring.
• Once stabilized, transition to oral antihypertensives should occur as soon as feasible, with medications timed appropriately around dialysis sessions to maintain consistent blood pressure control, as outlined in the guidelines 1.
• The most recent study on intravenous drugs for the treatment of hypertensive emergencies provides a comprehensive overview of the available options, including their onset and duration of action, dose, contraindications, and adverse effects 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Labetalol HCl Injection is intended for intravenous use in hospitalized patients. CLINICAL PHARMACOLOGY The principal pharmacological action of sodium nitroprusside is relaxation of vascular smooth muscle and consequent dilatation of peripheral arteries and veins.

The intravenous (IV) hypertension medications used in hospitalized patients, which may include those with End-Stage Renal Disease (ESRD), are:

• Labetalol (IV): used for the management of hypertension in hospitalized patients 2
• Nitroprusside (IV): used for the management of acute hypertension in hospitalized patients 3

Note: The FDA drug labels do not explicitly state the use of these medications specifically for ESRD patients, but they can be used in hospitalized patients with hypertension.

From the Research

Intravenous Hypertension Medications in End-Stage Renal Disease (ESRD)

• The following intravenous (IV) antihypertensive agents are used to treat hypertensive emergencies:
  • labetalol
  • esmolol
  • fenoldopam
  • nicardipine
  • sodium nitroprusside
  • clevidipine 4, 5, 6
• Sodium nitroprusside is an extremely toxic drug and its use in the treatment of hypertensive emergencies should be avoided 4, 5, 6
• Medications such as hydralazine, immediate release nifedipine, and nitroglycerin should be avoided due to significant toxicities and/or side effects 4, 5, 6

Considerations for ESRD Patients

• Control of extracellular volume with ultrafiltration and dietary sodium restriction represents the principal strategy to manage hypertension in ESRD 7
• Antihypertensive medications are subsequently added if this strategy is inadequate 7
• Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and beta-blockers are reasonable first-line agents for most ESRD patients 7
• Medications that are removed with dialysis may be preferred in patients who are prone to develop intradialytic hypotension 7