Can a patient with severely elevated blood pressure (hypertension) be given an antirabies vaccine?

Rabies Vaccination in Patients with Severely Elevated Blood Pressure

Yes, a patient with severely elevated blood pressure should receive antirabies vaccine without delay, as hypertension is not a contraindication to rabies post-exposure prophylaxis, and rabies is universally fatal without treatment. 1, 2

Key Principle: Rabies is a Medical Emergency

• Rabies post-exposure prophylaxis must be initiated immediately regardless of any concurrent medical conditions, including severe hypertension. 1, 3
• The mortality rate of rabies approaches 100% once clinical symptoms develop, making prevention through vaccination the only effective intervention. 4
• There are no absolute contraindications to rabies vaccination when exposure has occurred. 1

Why Hypertension Does Not Preclude Vaccination

• The rabies vaccine and rabies immunoglobulin (HRIG) can be safely administered to patients with any level of blood pressure elevation. 1
• The ACIP guidelines explicitly state that the vaccine is recommended "regardless of the time interval between exposure and initiation," with no mention of blood pressure as a contraindication. 1
• While rare cases of transient blood pressure increases have been reported after other vaccines (COVID-19), these are self-limited and do not represent a contraindication to life-saving rabies prophylaxis. 5

Standard Post-Exposure Prophylaxis Protocol

For previously unvaccinated patients:

• Administer HRIG at 20 IU/kg body weight on day 0, infiltrating the full dose around and into wounds if anatomically feasible. 2, 3
• Give rabies vaccine (HDCV or PCECV) 1.0 mL intramuscularly in the deltoid on days 0,3,7, and 14. 1, 3
• For immunocompromised patients, use a 5-dose schedule (days 0,3,7,14, and 28). 1, 3

For previously vaccinated patients:

• Give only vaccine (no HRIG) on days 0 and 3. 1, 2

Concurrent Blood Pressure Management

• While administering rabies prophylaxis, simultaneously initiate or optimize antihypertensive therapy according to standard hypertension guidelines. 1
• For severely elevated blood pressure (≥180/120 mmHg), consider immediate blood pressure lowering with appropriate agents (ACE inhibitors, ARBs, CCBs, or diuretics) while proceeding with rabies vaccination. 1
• The target systolic blood pressure should be 120-129 mmHg in most adults, but this should not delay rabies prophylaxis. 1

Critical Pitfalls to Avoid

• Never delay or withhold rabies post-exposure prophylaxis for any reason, including uncontrolled hypertension. 1, 3
• Never administer the vaccine in the gluteal area, as this produces inadequate antibody titers. 1, 3
• Never give HRIG to previously vaccinated persons, as it will suppress the anamnestic response. 2, 3
• Never administer HRIG and vaccine in the same syringe or anatomical site. 1, 3

Monitoring Considerations

• Monitor blood pressure before and after vaccination only if the patient has high cardiovascular risk, but do not delay vaccination for monitoring. 5
• If a transient blood pressure increase occurs after vaccination (rare), it is typically benign, self-limited, and resolves within 3-4 days. 5