From the Guidelines
When Cardene (nicardipine) drip is at maximum dosage and blood pressure remains uncontrolled, the next drug typically used is sodium nitroprusside (Nipride). Sodium nitroprusside is a potent, rapid-acting vasodilator that can be titrated easily for immediate blood pressure control, as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. The starting dose is usually 0.3-0.5 mcg/kg/minute, titrated every few minutes to a maximum of 10 mcg/kg/minute. However, it should not be used for more than 48-72 hours due to the risk of cyanide toxicity.
Some key points to consider when using sodium nitroprusside include:
- It is a vasodilator that acts by releasing nitric oxide, leading to relaxation of vascular smooth muscle 1
- It should be used with caution in patients with renal impairment, as it can worsen renal function 1
- It is contraindicated in patients with cyanide toxicity, as it can worsen this condition 1
Alternative options include:
- Labetalol (starting at 2 mg/minute), which is a combined alpha- and beta-blocker that can be used in patients with hypertensive emergencies, especially those with hyperadrenergic syndromes 1
- Clevidipine (starting at 1-2 mg/hour), which is a calcium channel blocker that can be used in patients with hypertensive emergencies, especially those with acute coronary syndromes or acute pulmonary edema 1
- Fenoldopam (starting at 0.1 mcg/kg/minute), which is a dopamine receptor agonist that can be used in patients with hypertensive emergencies, especially those with acute renal failure 1
The choice of the next agent depends on the patient's specific condition, including heart rate, renal function, and contraindications. Continuous blood pressure monitoring is essential when transitioning between medications, and plans should be made to transition to oral antihypertensives once the patient is stable. The selection of the next agent should consider the mechanism of action, with a different class often providing synergistic effects for better blood pressure control. According to the European Heart Journal, the use of labetalol, nitroprusside, and nicardipine are recommended as first-line or alternative treatments for various hypertensive emergencies 1.
From the Research
Next Line of Treatment for Hypertension
When Cardene (nicardipine) drip is at maximum, the next line of treatment for controlling blood pressure may involve alternative intravenous antihypertensive agents.
- The choice of agent depends on the patient's clinical presentation, comorbidities, and the presence of end-organ damage 2, 3.
- Options for intravenous antihypertensive agents include:
- Labetalol: a mixed alpha- and beta-blocker that can be used in patients with hypertensive emergencies, including those with acute stroke or intracerebral hemorrhage 4, 5.
- Esmolol: a selective beta-blocker with a rapid onset and short duration of action, suitable for patients with hypertensive emergencies who require quick blood pressure control 2, 3.
- Fenoldopam: a dopamine receptor agonist that can be used in patients with hypertensive emergencies, particularly those with renal impairment or heart failure 2, 3.
- Clevidipine: a calcium channel blocker with a rapid onset and short duration of action, which may be used as an alternative to nicardipine in patients with hypertensive emergencies 2, 3.
Considerations for Agent Selection
The selection of a specific agent should be based on the agent's pharmacology and patient-specific factors, such as:
- Comorbidities: certain agents may be more suitable for patients with specific comorbidities, such as renal impairment or heart failure 3.
- Presence of end-organ damage: patients with acute end-organ damage may require more aggressive blood pressure control with agents that have a rapid onset of action 2, 3.
- Tolerability: the ability to titrate the agent to the patient's tolerance levels is an important consideration, particularly in critically ill patients or those undergoing surgery 6.