What is the role of Mannitol in hypertensive emergency?

From the Guidelines

Mannitol is not recommended for the management of hypertensive urgency. Hypertensive urgency is best treated with oral antihypertensive medications such as labetalol (200-400 mg orally), captopril (25 mg orally), or amlodipine (10 mg orally), with the goal of gradually reducing blood pressure over 24-48 hours. Mannitol is an osmotic diuretic primarily used to reduce intracranial pressure in conditions like cerebral edema or to manage acute kidney injury, not for blood pressure control. Using mannitol in hypertensive urgency could cause rapid fluid shifts, potentially worsening the patient's condition through dehydration or electrolyte imbalances. Additionally, the osmotic diuresis from mannitol might lead to unpredictable blood pressure changes rather than controlled reduction. For hypertensive urgency, the focus should be on gradual blood pressure reduction with appropriate oral antihypertensives while addressing the underlying cause, monitoring for end-organ damage, and ensuring appropriate follow-up care.

The most recent and highest quality study, 1, supports the use of oral antihypertensive medications for the management of hypertensive urgency, and does not recommend the use of mannitol for this condition. The study emphasizes the importance of gradual blood pressure reduction and monitoring for end-organ damage in patients with hypertensive urgency.

Some key points to consider when managing hypertensive urgency include:

• Gradually reducing blood pressure over 24-48 hours with oral antihypertensive medications
• Monitoring for end-organ damage and addressing the underlying cause of the condition
• Ensuring appropriate follow-up care to prevent future episodes of hypertensive urgency
• Avoiding the use of mannitol and other intravenous medications that can cause rapid fluid shifts and unpredictable blood pressure changes.

Overall, the management of hypertensive urgency should focus on gradual blood pressure reduction with oral antihypertensive medications, while addressing the underlying cause and monitoring for end-organ damage.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Hypertensive Urgency and Mannitol

• There is no direct mention of mannitol in the provided studies as a treatment for hypertensive urgency.
• The studies focus on various antihypertensive agents used in the management of hypertensive emergencies and urgencies, such as sodium nitroprusside, nitroglycerin, hydralazine, nicardipine, fenoldopam, labetalol, esmolol, and clevidipine 2, 3, 4.
• Hypertensive urgency is defined as a condition where the blood pressure is elevated (diastolic > 120 mmHg) with the absence of acute target organ disease, and it can usually be managed with oral agents such as nifedipine, captopril, clonidine, labetalol, prazosin, and nimodipine 2.
• The selection of a specific agent for hypertensive emergency or urgency should be based on the agent's pharmacology and patient-specific factors, such as comorbidity and the presence of end-organ damage 4.

Management of Hypertensive Urgency

• Patients with hypertensive urgency are often treated with medications that lower their blood pressure acutely, although there is no evidence to support this practice 5.
• A systematic review of pharmacologic treatment of hypertensive urgency in the outpatient setting found that there is limited guidance regarding immediate management, and longitudinal studies are still needed to determine how best to lower blood pressure in patients with hypertensive urgency 6.
• The review also found that comorbidities and their potential contribution to long-term treatment of these subjects were not adequately addressed in any of the reviewed studies 6.