What is the recommended initial dose and titration schedule of Nicardia SR (nicardipine) for an adult with stage‑2 hypertension (blood pressure ~148/104 mmHg) who has no contraindications?

Nicardia SR (Nicardipine) Dosing for Stage-2 Hypertension

For an adult with stage-2 hypertension (BP ~148/104 mmHg) and no contraindications, start Nicardia SR (sustained-release nicardipine) at 20 mg three times daily, then titrate to 30–40 mg three times daily after at least 3 days to achieve steady-state plasma concentrations and optimal blood pressure control. 1

Initial Dosing Strategy

• Begin with 20 mg three times daily as the FDA-approved starting dose for hypertension management 1
• Allow at least 3 days before dose escalation to ensure achievement of steady-state plasma drug concentrations 1
• Effective doses range from 20 to 40 mg three times daily based on clinical trial data 1

Titration Protocol

• Measure blood pressure at trough (8 hours after dosing) to assess adequacy of response 1
• Also measure blood pressure 1–2 hours after dosing during initiation of therapy, as this is when maximum blood pressure lowering occurs 1
• Increase to 30 mg three times daily if blood pressure remains above target after 3 days at the initial dose 1
• Further titrate to 40 mg three times daily if needed, again waiting at least 3 days between adjustments 1

Evidence Supporting Oral Nicardipine Efficacy

• Oral nicardipine 30 mg achieved adequate blood pressure reduction (defined as diastolic BP <100 mmHg or ≥20 mmHg reduction) in 65% of patients with urgent hypertension versus 22% with placebo (p=0.002) 2
• In first-step monotherapy trials, nicardipine 20–30 mg three times daily controlled blood pressure (SBP <160 mmHg and DBP <95 mmHg) in 53% of patients versus 17% with placebo (p<0.001) 3
• Blood pressure reductions were maintained at 1 week after discharge in patients receiving 30–40 mg three times daily 2

Special Population Considerations

Renal Insufficiency

• Start with 20 mg three times daily and titrate carefully, though there is no evidence that nicardipine impairs renal function 1
• Nicardipine was safe and effective in elderly patients with renal dysfunction over 1 year of treatment at 20 mg three times daily 4

Hepatic Insufficiency

• Use 20 mg twice daily (not three times daily) as the starting dose in severely impaired hepatic function, with individual titration maintaining the twice-daily schedule 1

Elderly Patients

• No dose adjustment required based on age alone 4
• Nicardipine 20 mg three times daily was effective in reducing blood pressure in elderly patients (>60 years) with various types of renal dysfunction 4

Concomitant Antihypertensive Therapy

• Nicardipine may be safely coadministered with thiazide diuretics 1
• Nicardipine may be safely coadministered with beta-blockers 1
• When combined with pindolol 15 mg/day as second-step therapy, nicardipine produced larger blood pressure reductions (27±5 vs 15±3 mmHg systolic, p<0.01) than placebo 3

Monitoring Requirements

• Check blood pressure 1–2 hours post-dose to capture peak effect during initiation 1
• Check blood pressure at trough (8 hours post-dose) to assess sustained efficacy 1
• Monitor for common side effects: flushing (12%), headache (8%), ankle edema (5%), and asthenia (4%) 3

Critical Safety Considerations

Congestive Heart Failure

• Exercise caution when titrating in patients with congestive heart failure 1

Metabolic Effects

• Serum sodium, potassium, total cholesterol, and blood glucose levels remain unchanged with nicardipine administration 4
• Plasma renin activity and aldosterone levels show no significant changes 4

Common Pitfalls to Avoid

• Do not escalate dose before 3 days have elapsed, as steady-state concentrations require this time to develop 1
• Do not rely solely on trough measurements during initiation; peak effects at 1–2 hours post-dose are prominent and must be assessed 1
• Do not assume immediate-release and sustained-release formulations are interchangeable; Nicardia SR is a sustained-release preparation requiring three-times-daily dosing 1

Expected Hemodynamic Response

• Systolic blood pressure reduction of 21±2.5 mmHg and diastolic reduction of 13±2 mmHg can be expected with nicardipine versus minimal changes with placebo 3
• Heart rate may increase by approximately 10 beats/minute, though this effect is less pronounced than with nifedipine 5, 6
• Baroreflex sensitivity remains unchanged, but the set point resets to a lower pressure with chronic therapy 6