What prescription is recommended for severe hypertension?

Prescription for Severe Hypertension

For severe hypertension (BP ≥160/100 mmHg), initiate immediate-release oral nifedipine as first-line therapy in the outpatient setting, providing rapid BP reduction within 30-60 minutes without requiring IV access. 1

Initial Assessment and Verification

• Confirm persistent severe-range hypertension (>159/109 mmHg) by re-measuring BP within 15 minutes to verify this constitutes a medical emergency requiring treatment within 30-60 minutes 1
• Screen for target organ damage (acute chest pain, neurological symptoms, visual changes, dyspnea, altered mental status) to distinguish hypertensive emergency from urgency 2
• Assess for contraindications including pregnancy, acute MI, severe aortic stenosis, or bilateral renal artery stenosis before prescribing specific agents 2

First-Line Prescription

Immediate-release nifedipine is the preferred oral medication when IV access is unavailable or in outpatient settings due to its rapid onset suitable for urgent BP reduction 1

Dosing:

• Start with 10 mg immediate-release nifedipine orally 1
• Reassess BP after 30-60 minutes 1
• May repeat dose if inadequate response 1

Alternative Oral Agents (If Nifedipine Contraindicated)

If immediate-release nifedipine is unavailable or contraindicated:

• Captopril 25 mg orally (onset 15-30 minutes) 1
• Labetalol 200-400 mg orally (onset 30 minutes-2 hours) 2
• Avoid short-acting sublingual nifedipine due to unpredictable rapid BP drops 2

Blood Pressure Reduction Targets

Target a BP reduction of at least 20/10 mmHg, ideally toward 140/90 mmHg 1, 3

• Do NOT lower BP too rapidly - excessive reduction can cause organ hypoperfusion, particularly in patients with coronary artery disease or cerebrovascular disease 1, 3
• Avoid reducing mean arterial pressure by >25% in the first hour 2

Monitoring Parameters

• Check BP and heart rate before each dose 3
• Hold medication if systolic BP <90 mmHg, diastolic BP <60 mmHg, or heart rate <50 bpm 3
• Assess for orthostatic hypotension, especially in elderly patients 3
• Reassess for development of target organ damage that would necessitate transfer to emergency department 1

Long-Term Management Prescription

Once acute BP is controlled, initiate or optimize chronic antihypertensive therapy:

For Non-Black Patients:

1. Start with ACE inhibitor (lisinopril 10-40 mg daily) or ARB 2
2. Add thiazide diuretic (chlorthalidone 12.5-25 mg daily) or calcium channel blocker (amlodipine 5-10 mg daily) 2
3. Titrate to full doses before adding additional agents 2

For Black Patients:

1. Start with calcium channel blocker (amlodipine 5-10 mg daily) plus thiazide diuretic (chlorthalidone 12.5-25 mg daily) 2
2. Add ARB if needed 2

Resistant Hypertension (If BP Remains Uncontrolled on 3 Drugs)

Add spironolactone 25-50 mg daily as the preferred fourth agent 2

If spironolactone is not tolerated or contraindicated:

• Eplerenone 50-100 mg daily 2
• Amiloride, doxazosin, or bisoprolol 2
• Clonidine 0.1-0.8 mg twice daily (reserved as last-line due to CNS adverse effects) 2, 3

Critical Safety Warnings

• Never abruptly discontinue clonidine - must taper gradually to avoid hypertensive crisis 2, 3
• Avoid beta blockers as first-line unless patient has ischemic heart disease or heart failure 2
• Do NOT use ACE inhibitors or ARBs in pregnancy 2
• Avoid aggressive treatment of asymptomatic elevated BP in outpatient settings, as intensive treatment may be associated with worse outcomes including acute kidney injury and stroke 1

Follow-Up Plan

• Arrange outpatient follow-up within days to weeks depending on severity and response 1
• Achieve target BP within 3 months of therapy initiation 2, 3
• Do NOT discharge patients on intensified regimens without clear follow-up plans, as 9-14% of patients are inappropriately discharged with intensified medications 1

Common Pitfalls to Avoid

• Do not use nitroglycerin for acute severe hypertension management due to insufficient evidence and limited efficacy 1
• Avoid immediate-release nifedipine sublingual due to unpredictable precipitous BP drops 2
• Do not treat too aggressively - rapid BP reduction can precipitate stroke, MI, or acute kidney injury 1, 3