What is the recommended dosage and management of Nicardipine (calcium channel blocker) for hypertension or angina?

Nicardipine for Hypertension and Angina

Oral Nicardipine for Chronic Stable Angina

For chronic stable angina, begin with nicardipine 20 mg three times daily, titrating to 30-40 mg three times daily based on response, allowing at least 3 days between dose increases to achieve steady-state plasma concentrations. 1

• The effective dose range is 20-40 mg three times daily, with most patients requiring 30-40 mg three times daily for optimal anginal control 2, 3
• Clinical trials demonstrate that nicardipine increases treadmill exercise duration by 9%, time to angina by 15%, and time to 1-mm ST-segment depression by 16% 3
• Nicardipine can be safely coadministered with beta-blockers, short-acting and long-acting nitrates, and sublingual nitroglycerin for acute anginal attacks 1
• In patients with symptomatic angina requiring blood pressure lowering, beta-blockers and/or calcium channel blockers (including nicardipine) are recommended as part of that treatment 4

Common Side Effects in Angina Treatment

• Vasodilatory effects including flushing (12%), headache (8%), peripheral edema (5%), and palpitations are the most common side effects, typically mild and transient 2, 5, 3
• Approximately 3 patients in clinical trials experienced increased angina judged as probably drug-related, requiring careful monitoring during initiation 3

Oral Nicardipine for Chronic Hypertension

For mild to moderate hypertension, initiate nicardipine at 20 mg three times daily, titrating to 20-40 mg three times daily based on blood pressure response, with at least 3 days between dose adjustments. 1

• Maximum blood pressure lowering occurs 1-2 hours after dosing; measure blood pressure at both peak (1-2 hours) and trough (8 hours) to assess adequacy of response 1
• Clinical trials show nicardipine lowers supine systolic blood pressure by 10-15 mm Hg and diastolic blood pressure by 10 mm Hg 2
• Nicardipine can be safely combined with thiazide diuretics and beta-blockers 1
• A clear dose-response relationship exists from 10-40 mg three times daily 2

Special Populations for Oral Nicardipine

• Renal insufficiency: Begin with 20 mg three times daily with careful dose titration, though no evidence suggests nicardipine impairs renal function 1
• Hepatic insufficiency: Start with 20 mg twice daily (not three times daily) with individual titration based on clinical findings 1
• Congestive heart failure: Exercise caution when titrating dosage, as nicardipine may have advantages over other vasodilators by not depressing cardiac conduction or left ventricular function even in compromised cardiac pumping ability 1, 5

Intravenous Nicardipine for Hypertensive Emergencies

For hypertensive emergencies, intravenous nicardipine is a first-line agent starting at 5 mg/hour, increasing every 15 minutes by 2.5 mg/hour to a maximum of 15 mg/hour, with onset of action in 5-15 minutes. 6, 7

• In pre-eclampsia or eclampsia with hypertensive crisis, intravenous labetalol or nicardipine combined with magnesium is recommended 4
• Nicardipine is preferred for acute renal failure, eclampsia/preeclampsia, and perioperative hypertension 8, 6
• Duration of action is 30-40 minutes, though effects may extend beyond 4 hours 8, 7
• The American College of Cardiology suggests nicardipine may be superior to labetalol for achieving short-term blood pressure targets and is preferred when beta-blockers are contraindicated 7

Blood Pressure Reduction Goals in Hypertensive Emergencies

• Reduce mean arterial pressure by 20-25% within the first hour, then aim for blood pressure <160/100 mm Hg over the next 2-6 hours 6, 7
• Avoid overly rapid blood pressure reduction exceeding 50% decrease in mean arterial pressure, as this is associated with ischemic stroke and death 7
• For specific conditions like aortic dissection (systolic blood pressure <120 mm Hg within 20 minutes) or pulmonary edema (systolic blood pressure <140 mm Hg immediately), different targets apply 7

Condition-Specific Recommendations for IV Nicardipine

• Acute renal failure: Nicardipine is a preferred agent alongside clevidipine and fenoldopam 6
• Eclampsia/preeclampsia: Nicardipine is recommended alongside hydralazine and labetalol, with both labetalol and nicardipine shown to be safe and effective 4, 6
• Perioperative hypertension: Nicardipine is preferred alongside clevidipine, esmolol, and nitroglycerin 6
• Autonomic hyperreactivity (cocaine/amphetamine intoxication): Nicardipine can be considered after benzodiazepines are initiated first, alongside phentolamine or nitroprusside 4

Critical Pitfalls to Avoid

• Do not use oral nicardipine for true hypertensive emergencies requiring immediate intravenous therapy 6, 7
• Monitor for local phlebitis at infusion sites, which can occur after 14 hours of continuous infusion at a single site; rotate sites to reduce incidence 9
• Nicardipine increases heart rate by approximately 10 beats/minute, though this is generally well tolerated 9, 3
• Ensure foetal heart rate monitoring when using nicardipine in pre-eclampsia/eclampsia 4