Rethinking some hypertension medications

PHILADELPHIA — Nitroprusside has been a component of CVD management for more than 40 years, but a speaker at the American College of Physicians Internal Medicine Meeting encouraged attendees to rethink its purpose in treating malignant hypertension in inpatient settings.

“Nitroprusside is less predictable in its clinical impact in this space than many other drugs I can recommend. “In some patients that take this medication, their BP plummets to the floor,” R. Neal Axon, MD, MSCR, associate professor at the College of Medicine at the Medical University of South Carolina said.

There are other concerns associated with the medication, Axon said.

“When nitroprusside was used as the primary agent for patients in the STAT registry [a cohort of nearly 1,588 patients (mean age, 58 years; 49% women; 56% black) who were treated for acute severe hypertension] a second or third agent was often required,” he continued.

Nitroprusside has also been linked to increased intracranial pressure, incidents of cyanide toxicity, and cases where blood is shunted away from potential ischemia, Axon said, adding these consequences prompted him to look for alternative medications for patients with malignant hypertension in inpatient settings.
“I am a big fan of nicardipine, a second generation dihydropyridine calcium channel blocker. The onset of action is about 5 minutes, the offset is less than 30 minutes, and the drug has favorable cerebrovascular effects,” he continued.

Nicardipine doses should start at 5 mg per hour, increase to 2.5 mg per hour to a maximum of 30 mg per hour, Axon said.

“Even cooler is clevidipine, a third generation dihydropyridine calcium channel blocker,” Axon said. “It has an onset of action that is less than a minute, and because it metabolizes by plasma esterases, it stops working just as fast, and also increases stroke volume cardiac output.”

Doses of clevidipine should start at 12 mg per hour to a maximum of 16 mg per hour, according to Axon. – by Janel Miller

References:

Axon RN. “Hypertension management of the inpatient: When high isn't a good thing.” Presented at: ACP Internal Medicine Meeting; April 11-13, 2019; Philadelphia.

Hottinger DG, et al. J Anaesthesiol Clin Pharmacol. 2014;doi:10.4103/0970-9185.142799.

Disclosures: Axon reports no relevant financial disclosures.