What is the guideline for dose reduction of Cardene (nicardipine) drip in managing hypertensive urgency?

Nicardipine (Cardene) Drip Dose Reduction Guidelines for Hypertensive Urgency

Once goal blood pressure is achieved with nicardipine infusion, decrease the infusion rate to 3 mg/h for maintenance therapy. 1

Titration Protocol

Initial Dosing and Titration Up

• Start at 5 mg/h as the initial infusion rate 1
• Increase by 2.5 mg/h every 15 minutes for gradual blood pressure reduction, up to a maximum of 15 mg/h 1, 2
• For more rapid blood pressure reduction, titrate every 5 minutes instead of every 15 minutes 2
• The maximum infusion rate is 15 mg/h 1, 2

Maintenance Dosing After Goal Achievement

• Once goal blood pressure is reached, decrease the infusion rate to 3 mg/h 1
• This maintenance dose should be continued while monitoring blood pressure response 1
• Adjust the infusion rate as needed to maintain the desired blood pressure response 2

Blood Pressure Reduction Targets

For Hypertensive Urgency (No End-Organ Damage)

• Reduce systolic blood pressure by no more than 25% within the first hour 1
• Then reduce to 160/100 mm Hg within the next 2-6 hours if the patient remains stable 1
• Cautiously normalize blood pressure over the following 24-48 hours 1

This gradual approach prevents precipitous drops in blood pressure that could compromise organ perfusion, particularly in patients with chronic hypertension who have adapted to higher baseline pressures 1.

Pharmacokinetics and Timing

• Onset of action: 5-15 minutes after starting infusion 1
• Duration of action: 30-40 minutes after discontinuation 1
• Blood pressure begins to fall within minutes of infusion initiation 2
• With constant infusion, blood pressure reaches approximately 50% of its ultimate decrease in about 45 minutes 2

Critical Safety Considerations

Hypotension or Tachycardia Management

• If hypotension or tachycardia develops, immediately discontinue the infusion 2
• Once blood pressure and heart rate stabilize, restart at low doses of 3-5 mg/h (30-50 mL/h) and titrate carefully to maintain desired blood pressure 2

Infusion Site Management

• Change the infusion site every 12 hours when administered via peripheral vein to minimize risk of phlebitis and venous irritation 2
• Avoid small veins such as those on the dorsum of the hand or wrist 2
• Local phlebitis can develop after 14+ hours of infusion at a single site 3

Special Populations Requiring Close Monitoring

• Congestive heart failure: Monitor closely during titration 2
• Impaired hepatic function: Use caution and monitor closely; nicardipine is contraindicated in liver failure 1, 2
• Renal impairment: Monitor closely during titration 2
• Portal hypertension: Exercise caution 2

Common Pitfalls to Avoid

• Do not reduce blood pressure too rapidly in hypertensive urgency—this can cause end-organ hypoperfusion and ischemic complications 1
• Do not continue infusion at high rates (>3 mg/h) once goal is achieved—the guideline-recommended maintenance dose is 3 mg/h 1
• Do not use the same peripheral IV site for more than 12 hours—this significantly increases phlebitis risk 2, 3
• Do not abruptly discontinue in patients on beta-blockers—nicardipine is not a beta-blocker and provides no protection against beta-blocker withdrawal 2

Adverse Effects to Monitor

• Headache (most common, 13% incidence) 2
• Reflex tachycardia (4% incidence) 1, 2
• Hypotension (5% incidence) 2
• Nausea/vomiting (4% incidence) 2
• Local phlebitis at infusion site 3

Transition to Oral Therapy

• When switching to oral nicardipine capsules (TID regimen), administer the first oral dose 1 hour prior to discontinuing the infusion 2
• For transition to other oral antihypertensive agents, initiate oral therapy upon discontinuation of the nicardipine infusion 2