What are the intravenous (IV) medication options for managing uncontrolled hypertension (high blood pressure)?

From the Guidelines

For uncontrolled hypertension requiring IV medication, the most recent and highest quality study recommends labetalol, nicardipine, and clevidipine as first-line options 1.

Key Considerations

• Labetalol can be given as 5 to 20 mg IV bolus every 15 minutes, with a continuous infusion rate of 2 mg/min (maximum 300 mg/d) 1.
• Nicardipine is typically started at 5 mg/hr and titrated by 2.5 mg/hr every 5-15 minutes up to 15 mg/hr 1.
• Clevidipine begins at 1-2 mg/hr and can be titrated by doubling the dose every 90 seconds initially, with a maximum of 32 mg/hr 1.

Important Notes

• The goal is to reduce blood pressure by no more than 25% in the first hour, then to 160/100-110 mmHg within the next 2-6 hours if tolerated 1.
• Continuous cardiac monitoring, frequent blood pressure checks, and assessment of end-organ damage are essential during treatment 1.
• The underlying cause of hypertension should be identified and addressed simultaneously, as IV medications are temporary measures until oral therapy can be established 1.

Comorbidities and Special Considerations

• For acute aortic dissection, esmolol and labetalol are preferred, with a goal of reducing SBP to ≤120 mm Hg within 20 minutes 1.
• For acute pulmonary edema, clevidipine, nitroglycerin, and nitroprusside are preferred, with beta blockers contraindicated 1.
• For acute coronary syndromes, esmolol, labetalol, nicardipine, and nitroglycerin are preferred, with nitrates given in the presence of PDE-5 inhibitors potentially inducing profound hypotension 1.

From the FDA Drug Label

For a gradual reduction in blood pressure, initiate therapy at a rate of 5 mg/hr. If desired blood pressure reduction is not achieved at this dose, increase the infusion rate by 2.5 mg/hr every 15 minutes up to a maximum of 15 mg/hr, until desired blood pressure reduction is achieved. Titration For a gradual reduction in blood pressure, initiate therapy at a rate of 5 mg/hr. When treating acute hypertensive episodes in patients with chronic hypertension, discontinuation of infusion is followed by a 50% offset of action in 30 minutes ± 7 minutes but plasma levels of drug and gradually decreasing antihypertensive effects exist for many hours.

Nicardipine IV can be used for uncontrolled blood pressure.

• The initial dose is 5 mg/hr.
• The dose can be increased by 2.5 mg/hr every 15 minutes.
• The maximum dose is 15 mg/hr.
• Titration should be done to achieve the desired blood pressure reduction 2.

From the Research

BP Medication IV for Uncontrolled BP

• The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure 3, 4.
• Immediate reduction in blood pressure is required only in patients with acute end-organ damage (i.e. hypertensive emergency) and requires treatment with a titratable, short-acting, intravenous antihypertensive agent 3, 4.
• Rapid-acting intravenous antihypertensive agents are available, including:
  • Labetalol
  • Esmolol
  • Fenoldopam
  • Nicardipine
  • Sodium nitroprusside
  • Clevidipine 3, 4, 5
• Newer agents, such as clevidipine, may hold considerable advantages to other available agents in the management of hypertensive crises 3, 4, 5.
• Sodium nitroprusside is an extremely toxic drug and its use in the treatment of hypertensive emergencies should be avoided 3, 4.
• Clevidipine is effective in the treatment of both acute preoperative and postoperative hypertension in adult cardiac surgery patients, and has a rapid onset and short duration of action 5.
• Clevidipine is generally well tolerated in these patient populations, and has a safety profile generally similar to that of sodium nitroprusside, nitroglycerin, or nicardipine in cardiac surgery patients 5, 6.