Version May 2024
| 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 21 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 6 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, kidney function 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 20 mg IM (40 mg maximum per labeling) | 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 generally not exceed 2 mcg/kg per minute. Use of maximal dose (ie, 8 to 10 mcg/kg per minute) should not exceed 10 minutes. 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 | Due to its toxicity, nitroprusside should generally be avoided if preferred agents are available. Nitroprusside should be avoided in patients with AMI, CAD, CVA, elevated intracranial pressure, kidney function impairment, or hepatic impairment. |
| Adrenergic inhibitors | |||||
| Esmolol | 500 mcg/kg is typical loading dose given over 1 minute; then initiate IV infusion at 25 to 50 mcg/kg per minute; titrate incrementally up to maximum of 300 mcg/kg per minute. May consider repeating a loading dose (eg, ≤500 mcg/kg) prior to each up-titration step. | 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 3 to 6 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.
* The treatment of acute aortic syndromes (eg, acute aortic dissection, aortic intramural hematoma) requires specific medication management to minimize disease extension and is presented separately. Refer to UpToDate topics discussing acute aortic syndromes and acute aortic dissection.
¶ Hypotension may occur with all agents.
Δ IV short-acting agents for treatment of hypertensive emergency should be administered immediately by clinicians who are trained and experienced in their titration using continuous noninvasive electronic monitoring of blood pressure, heart rate, and cardiac rhythm. Patients should be admitted to an intensive care unit as rapidly as possible. A combination of IV agents is often selected depending upon the acute indication. Refer to appropriate UpToDate clinical topic for suggested combinations.
◊ Initial fenoldopam doses in range of 0.01 to 0.3 mcg/kg per minute have been described.آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
