Severe Symptomatic Hypertension (Hypertensive Crisis)

Clinic A/P, adults, Clinic A/P, Peds, Hospital A/P, Adults, Hospital A/P, Peds, Pharmacy and Therapeutics

Severe Symptomatic Hypertension (Hypertensive Crisis)

IV Drugs

Oral Medications

  • Clonidine 0.1-0.2 mg
  • Labetalol 200-400mg BID. Start: 100mg po BID, may increase by 200 mg / dayq2-3 days. Max 2400 mg/day. May divide dose TID. Taper dose over 1-2 wks to D/C.
  • Hydralazine 10-50 mg PO qid. Start: 10 mg po qid x 2-4 days, then 25 mg po qid x 1 week. Max: 300 mg/day PO.  Alternate: 10-40 mg IM/IV q4-6h. Switch to PO ASAP.
  • Captopril 12.5-50 mg tid. Start: 12.5-25 mg PO bid-tid, increase 12.5-25 mg/dose q1-2wk.

 

IV medications are really best for hypertensive crisis.

From Uptodate

Parenteral drugs for treatment of hypertensive emergencies in adults*
Drug Dose range Onset of action (minutes) Duration of action (minutes) Adverse effects RoleΔ
Vasodilators
Clevidipine Initially 1 to 2 mg/hour as IV infusion with rapid titration.

Most patients respond to 4 to 6 mg/hour and are treated with maximum doses of 16 mg/hour or less.

NOTE: Delivered in lipid emulsion. 1000 mL maximum per 24 hours (equivalent to 21 mg/hour) due to lipid load.

 2 to 4 5 to 15 Atrial fibrillation, nausea, lipid formulation contains potential allergens (eg, soy, egg) Hypertensive emergencies including postoperative hypertension.
Enalaprilat 1.25 to 5 mg every six hours IV 15 to 30 approximately 6 to >12 hours Precipitous fall in pressure in high-renin states; variable response, headache, dizziness Acute left ventricular failure.

Due to slow onset and long duration of effect, rarely used.

Avoid use in AMI, renal impairment, or pregnancy.
Fenoldopam Initially 0.1 mcg/kg per minute◊ as IV infusion titrated to a maximum of 1.6 mcg/kg per minute 5 to 10 30 to 60 Tachycardia, headache, nausea, flushing Most hypertensive emergencies.

Use caution or avoid with glaucoma or increased intracranial pressure.
Hydralazine 10 to 20 mg IV 10 to 20 IV 1 to ≥4 hours IV Sudden precipitous drop in blood pressure, tachycardia, flushing, headache, vomiting, aggravation of angina In general, hydralazine should be avoided due to its prolonged and unpredictable hypotensive effect.

Labetalol and nicardipine are generally preferred choices for treatment of eclampsia.
10 to 40 mg IM 20 to 30 IM 4 to 6 hours IM
Nicardipine 5 to 15 mg/hour as IV infusion.

Some patients may require up to 30 mg/hour.

 5 to 15 approximately 1.5 to ≥4 hours Tachycardia, headache, dizziness, nausea, flushing, local phlebitis, edema Most hypertensive emergencies, including pregnancy induced.

Avoid use in acute heart failure.

Caution with coronary ischemia.
Nitroglycerin (glyceryl trinitrate) 5 to 100 mcg/minute as IV infusion 2 to 5 5 to 10 Hypoxemia, tachycardia (reflex sympathetic activation), headache, vomiting, flushing, methemoglobinemia, tolerance with prolonged use Potential adjunct to other IV antihypertensive therapy in patients with coronary ischemia (ACS) or acute pulmonary edema.
Nitroprusside 0.25 to 10 mcg/kg per minute as IV infusion.

To minimize risk of cyanide toxicity, infusion duration should be as short as possible and not exceed 2 mcg/kg per minute.

Patients who receive higher doses (ie, >500 mcg/kg at a rate exceeding 2 mcg/kg per minute) should receive sodium thiosulfate infusion to avoid cyanide toxicity.

 0.5 to 1 1 to 10 Elevated intracranial pressure, decreased cerebral blood flow, reduced coronary blood flow in CAD, cyanide and thiocyanate toxicity, nausea, vomiting, muscle spasm, flushing, sweating In general, nitroprusside should be avoided due to its toxicity.

Nitroprusside should be avoided in patients with AMI, CAD, CVA, elevated intracranial pressure, renal impairment, or hepatic impairment.
Adrenergic inhibitors
Esmolol 250 to 500 mcg/kg loading dose over one minute; then initiate IV infusion at 25 to 50 mcg/kg per minute; titrate incrementally up to maximum of 300 mcg/kg per minute 1 to 2 10 to 30 Nausea, flushing, bronchospasm, first-degree heart block, infusion-site pain; half-life prolonged in setting of anemia Perioperative hypertension.

Avoid use in acute decompensated heart failure.
Labetalol Initial bolus of 20 mg IV followed by 20 to 80 mg IV bolus every 10 minutes (maximum 300 mg)

or 
0.5 to 2 mg/minute as IV loading infusion following an initial 20 mg IV bolus (maximum 300 mg)

 5 to 10 2 to 4 hours Nausea/vomiting, paresthesias (eg, scalp tingling), bronchospasm, dizziness, nausea, heart block Most hypertensive emergencies including myocardial ischemia, hypertensive encephalopathy, pregnancy, and postoperative hypertension.

Avoid use in acute decompensated heart failure.

Use cautiously in obstructive or reactive airway.
Metoprolol Initially 1.25 to 5 mg IV followed by 2.5 to 15 mg IV every three to six hours 20 5 to 8 hours Refer to labetalol Myocardial ischemia, perioperative hypertension.

Avoid use in acute decompensated heart failure.
Phentolamine 5 to 15 mg IV bolus every 5 to 15 minutes 1 to 2 10 to 30 Tachycardia, flushing, headache, nausea/vomiting Alternative option for catecholamine excess (eg, adrenergic crisis secondary to pheochromocytoma or cocaine overdose).
IV: intravenous injection; AMI: acute myocardial infarction; IM: intramuscular injection; ACS: acute coronary syndrome; CAD: coronary artery disease; CVA: cerebrovascular accident.
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