Nicardipine Dosing and Management
Intravenous Nicardipine for Hypertensive Emergencies
For hypertensive emergencies, start nicardipine at 5 mg/hour IV, increase by 2.5 mg/hour every 5 minutes to a maximum of 15 mg/hour until blood pressure target is achieved. 1
Dosing Protocol
- Initial dose: 5 mg/hour IV infusion 1
- Titration: Increase by 2.5 mg/hour increments every 5 minutes 1
- Maximum dose: 15 mg/hour 1
- Onset of action: Blood pressure reduction begins within 1-5 minutes 1
- Duration of effect: 4-6 hours after discontinuation 1
Clinical Context for IV Use
- Admission required: All hypertensive emergencies require ICU admission for continuous blood pressure monitoring and parenteral therapy 1
- Blood pressure targets vary by clinical scenario:
- Compelling conditions (aortic dissection, severe preeclampsia/eclampsia, pheochromocytoma): Reduce SBP to <140 mm Hg within first hour, <120 mm Hg for aortic dissection 1
- Non-compelling conditions: Reduce SBP by no more than 25% within first hour, then to 160/100 mm Hg over next 2-6 hours, then cautiously to normal over 24-48 hours 1
Specific Clinical Scenarios Where Nicardipine is Preferred
Nicardipine is specifically recommended for: 1
- Acute coronary syndromes (with esmolol, labetalol, or nitroglycerin) 1
- Acute renal failure (with clevidipine or fenoldopam) 1
- Eclampsia/preeclampsia (with hydralazine or labetalol) 1
- Perioperative hypertension (BP ≥160/90 mm Hg or SBP elevation ≥20% preoperative value persisting >15 minutes) 1
- Acute sympathetic discharge/catecholamine excess states (pheochromocytoma, post-carotid endarterectomy) 1
Evidence for Superiority
Two trials demonstrated that nicardipine may be superior to labetalol in achieving short-term blood pressure targets in hypertensive emergencies. 1
Pregnancy-Specific Dosing
- Starting dose: 5 mg/hour IV 1
- Titration: Increase by 2.5 mg/hour every 5-15 minutes 1
- Maximum dose: 15 mg/hour 1
- Onset: 1-5 minutes 1
- Duration: 4-6 hours 1
- Safety: Can be used as alternative to labetalol and hydralazine for severe hypertension in pregnancy 1
Oral Nicardipine for Chronic Management
Angina Pectoris
For chronic stable angina, start nicardipine 20 mg three times daily, with effective doses ranging from 20-40 mg three times daily. 2
- Initial dose: 20 mg orally three times daily 2
- Effective dose range: 20-40 mg three times daily 2, 3
- Titration interval: Allow at least 3 days between dose increases to achieve steady-state plasma concentrations 2
- Peak effect timing: Maximum blood pressure lowering occurs 1-2 hours after dosing 2
Hypertension
For chronic hypertension, start nicardipine 20 mg three times daily, with effective doses ranging from 20-40 mg three times daily. 2
- Initial dose: 20 mg orally three times daily 2
- Effective dose range: 20-40 mg three times daily 2, 3
- Titration interval: At least 3 days between increases 2
- Blood pressure monitoring: Measure at trough (8 hours after dosing) to assess adequacy of response 2
- Peak effect monitoring: Also measure 1-2 hours after dosing, particularly during initiation 2
Special Populations
Renal Insufficiency:
- Start with 20 mg three times daily with careful titration 2
- No evidence that nicardipine impairs renal function 2
Hepatic Insufficiency:
- Start with 20 mg twice daily (note the reduced frequency) 2
- Administer cautiously in severely impaired hepatic function 2
- Maintain twice-daily schedule with individual titration 2
Congestive Heart Failure:
- Exercise caution when titrating dosage 2
- Nicardipine increases cardiac index by 64%, stroke volume by 35%, and reduces systemic vascular resistance by 50% in patients with mild-to-moderate left ventricular failure 4
- Mild-to-moderate left ventricular failure is not a contraindication to nicardipine therapy 4
Combination Therapy
Safe Coadministration
Nicardipine can be safely combined with: 2
- Beta-blockers (for both angina and hypertension) 2
- Nitrates (sublingual for acute anginal attacks; short- and long-acting for prophylaxis) 2
- Thiazide diuretics (for hypertension) 2
Angina Management Strategy
For hypertensive patients with chronic stable angina, use a regimen including beta-blocker (especially if prior MI), ACE inhibitor or ARB (if diabetes/LV dysfunction), and thiazide diuretic. 1
- If beta-blockers are contraindicated or cause intolerable side effects, a nondihydropyridine CCB (diltiazem or verapamil) may substitute, but not if LV dysfunction is present 1
- If angina or hypertension remains uncontrolled, add a long-acting dihydropyridine CCB (like nicardipine) to the basic regimen 1
- Caution: Combining beta-blocker with nondihydropyridine CCBs increases risk of significant bradyarrhythmias and heart failure 1
Contraindications and Precautions
Absolute Contraindications
Important Precautions
- No dose adjustment needed for elderly patients (unlike clevidipine) 1
- Monitor for bradycardia when used with beta-blockers 1
- Avoid in decompensated heart failure when combined with beta-blockers 1
- Local phlebitis can develop at IV infusion site after ≥14 hours; rotate sites more frequently 5
Adverse Effects
Common Side Effects (Dose-Related)
The most frequent adverse effects are due to vasodilation: 3, 6
- Flushing 3, 6
- Headache 3, 6, 1
- Palpitations 3
- Peripheral edema 3, 6
- Tachycardia (heart rate increases approximately 10 beats/minute with IV use) 5, 1
Timing of Side Effects
Clinical Pearls
Pharmacokinetics
- Onset with IV: 1-5 minutes 1
- Peak effect with oral: 1-2 hours 2
- Duration after IV discontinuation: 4-6 hours 1
- Steady-state: Achieved after 3 days of consistent dosing 2
- Linear kinetics: Excellent correlation between plasma levels and blood pressure reduction 7
Advantages Over Nifedipine
- Less negative inotropic effect than nifedipine 5
- Less reflex tachycardia than nifedipine 5
- Does not depress cardiac conduction or left ventricular function, even in patients with compromised cardiac pumping ability 6