What is the appropriate dosing and administration of Nicardipine (nicardipine) for acute hypertension?

Nicardipine IV Push is NOT Recommended

Nicardipine should be administered as a continuous intravenous infusion, NOT as an IV push or bolus injection. 1, 2 The FDA-approved formulation and all major guidelines specify continuous infusion only, as bolus administration can cause unpredictable and dangerous blood pressure fluctuations.

Correct Administration Method

Standard IV Infusion Protocol

• Start at 5 mg/hr as a continuous IV infusion 1, 3, 4, 2
• Titrate by 2.5 mg/hr increments every 5-15 minutes depending on urgency 1, 3, 4
  • For rapid BP reduction: increase every 5 minutes 1, 3
  • For gradual BP reduction: increase every 15 minutes 1, 3
• Maximum dose: 15 mg/hr 1, 3, 4, 2
• Onset of action: 5-15 minutes with duration of 30-40 minutes after discontinuation 1, 4

Preparation Requirements

• Single-dose vials (25 mg/10 mL) must be diluted before use 2
• Pre-mixed flexible containers (0.1 mg/mL or 0.2 mg/mL) are available and preferred 2
• Change infusion site every 12 hours to minimize risk of phlebitis and venous irritation 2

Blood Pressure Reduction Goals

• Reduce systolic BP by no more than 25% within the first hour 3, 5
• Target BP <160/100 mmHg within 2-6 hours if stable 3, 5
• Avoid rapid drops that can cause end-organ hypoperfusion, particularly in stroke patients 4, 5

Clinical Context for Nicardipine Use

Preferred Scenarios

• Acute renal failure - nicardipine is a preferred agent 3
• Eclampsia/preeclampsia - safe and effective alongside labetalol 1, 3
• Perioperative hypertension - excellent titratable option 3, 6
• Acute ischemic stroke with BP >185/110 mmHg before thrombolysis 4

Not First-Line For

• Most hypertensive emergencies - labetalol is generally preferred due to combined alpha/beta blockade 3, 5
• Hypertensive urgency - oral agents (captopril, labetalol, extended-release nifedipine) are preferred 3

Critical Safety Considerations

Monitoring Requirements

• Continuous BP monitoring during titration 4, 5
• Check BP every 15 minutes for first 2 hours, then every 30 minutes for 6 hours, then hourly 4
• Monitor for hypotension and tachycardia - if either occurs, discontinue infusion immediately 2

Vascular Access Precautions

• Avoid small veins (dorsum of hand or wrist) to reduce thrombophlebitis risk 2
• Never administer intra-arterially or allow extravasation 2
• Phlebitis can develop after 14+ hours at a single site - rotate sites every 12 hours 2, 7

Special Population Warnings

• Stroke patients: Exercise extreme caution to avoid systemic hypotension, which worsens neurologic outcomes 4, 5
• Hepatic impairment/portal hypertension: Requires close monitoring and likely dose reduction 1, 2
• Contraindicated in advanced aortic stenosis 2

Common Adverse Effects

• Headache (13%) - most common side effect 2
• Hypotension (5%) and tachycardia (4%) - dose-dependent 2
• Flushing - common with all dihydropyridines 4, 7
• Nausea/vomiting (4%) 2

Drug Interactions

• Cimetidine increases nicardipine levels - use caution if co-administered 2
• Nicardipine increases cyclosporine and tacrolimus levels - monitor immunosuppressant trough levels closely 2

Transition to Oral Therapy

• When converting from IV to oral nicardipine: 4
  • Oral 30 mg TID = IV 1.2 mg/hr
  • Oral 40 mg TID = IV 2.2 mg/hr
• Alternative oral agents (ACE inhibitors, ARBs, beta-blockers, long-acting CCBs) should be selected based on comorbidities 4, 5

Key Pitfall to Avoid

Never administer nicardipine as an IV push or bolus. The 5 mg dose mentioned in your question likely refers to the starting infusion rate of 5 mg/hr, not a push dose. Bolus administration is not FDA-approved and can cause dangerous, uncontrolled hypotension. 2