Nicardipine Hydrochloride

NiCARdipine Hydrochloride

Brand names Cardene IV, generic

Medication error Look-alike, sound-alike drug names. NiCARdipine has been confused with NIFEdipine, but potential no patient harm resulted.(1,2) NiCARdipine confusion with nimodipine and nitroprusside has resulted in result in harm. Cardene confusion with Cardizem, Cordarone, and NIFEdipine did not result, no patient harm occurred.(2) ISMP recommends the following tall man letters: NiCARdipidine.(31)

Contraindications Contraindications: Do not use in patients with hypersensitivity to nicardipine or to and warnings patients with advanced aortic stenosis.(3) Warnings: Use caution when administering nicardipine, particularly in combination with beta-blocker therapy, in patients with heart failure, or significant left ventricular dysfunction.(3) (See the Dosage Adjustment in Organ Dysfunction section.) Also use caution when administering nicardipine to patients with pheochromocytoma.(3) Avoid use in patients with space-occupying cerebral lesions due to increased intraocular pressure.(4)

Infusion-related If administered via a large peripheral line or via a central line. Avoid extravasation cautions as tissue damage may occur. Change sites every 12 hours to avoid venous irritation/ thrombophlebitis.(3,5)

Dosage Severe hypertension: Because oral and IV mg doses are not equivalent, caution should be used in calculating dosage when transitioning between products.(3) Neonates (preterm): Begin with 0.5 mcg/kg/min and titrate q 15–30 min until target blood pressure is achieved.(6,7) Has been given for up to 36–43 days. Neonates (term) and infants: Begin with 0.5–1 mcg/kg/min and titrate q 15–30 min until target blood pressure is achieved. Normal maintenance doses range from 1.5–3 mcg/kg/min.(8,10) Children 1–17 years: Begin with doses ranging from 1–5 mcg/kg/min.(4,8-16); some patients have received an initial dose of 10 mcg/kg/min.(11,13) Maintenance doses typically range from 1–3 mcg/kg/min (up to 6 mcg/kg/min). Dose should be titrate q 15–30 min until target blood pressure is achieved.(4,9,11-15,17-22,30) In hypertensive emergencies, blood pressure should be frequently monitored to ensure that it does not decrease too quickly.(24) One group recommended that blood pressure decrease by one-third of the desired total blood pressure within 6 hours, a further one- third decrease within the next 24–36 hours, with the final one-third decrease achieved over the next 48–72 hours.(18) Alternatively, a blood pressure decrease of <25% over the first 8 hours followed by gradual normalization over 26–48 hours.(17)

Dosage adjustment No dose adjustment is recommended for renal impairment; however, patients with renal in organ dysfunction insufficiency may accumulate drug and respond to lower doses. For these reasons, con- servative doses are recommended.(19,26) Nicardipine is extensively metabolized by the liver.(3) This results in elevation of serum concentration and prolonged half-life in those with hepatic failure or uremia and half- life prolonged in those with hepatic failure or uremia; therefore, dose adjustment is warranted.(19,26) Two case reports suggest that dosage changes are not required in patients on ECMO.(10,14) Although one reference suggests that nicardipine may be used in children with cardiac disease,(27) the manufacturer recommends caution when administering nicardipine to patients with heart failure or significant left ventricular dysfunction due to a potential negative inotropic effect.(3)  648 NiCARdipine Hydrochloride

Maximum dosage 10 mcg/kg/min (5 mg/hr in adults) has been used as an initial dose.(11,13) Up to 6 mcg/ kg/min (15 mg/hr in adults) has been given as a maintenance dose(21) Initial maximum adult doses of 5 mg/hr should be followed by titration of dose by 2.5 mg/hr until a dose of 15 mg/hr is achieved.

Additives None

Suitable diluents D5W, D5NS, D5½NS, D5W with 40 mEq/L potassium, NS, ½NS.(5) Nicardipine is not com- patible with sodium bicarbonate or LR.(3,5)

Maximum 0.1 mg/mL.(3) A concentration of 3.6 mg/mL has been infused safely via a central line.(15) concentration

Preparation and Parenteral products should be visually inspected for particulate matter and discoloration delivery before use. Refer to appropriate references for more information on compatibility with other drugs and solutions; compatibility following Y-site delivery, and suggested storage and extended stability.(5) Stability: Normally a clear, yellow solution that should be stored at room temperature. Freez- ing does not adversely affect the product, but elevated temperatures should be avoided.(3,5) Delivery system issues: Nicardipine (Dupont Merck) 50 and 500 mg/L in a variety of infusion solutions in PVC containers showed a decline in concentrations with nearly 50% lost in 24 hours.(5) Drug concentrations were stable when prepared in glass containers.(5) Photosensitivity: Protected from light. Deliberate exposure of a solution of 0.1 mg/mL to daylight resulted in about 8% loss in 7 hours and 21% in 14 hours.(5)

IV push Not recommended(3,5)

Intermittent infusion Not recommended(3,5)

Continuous infusion 10 mL of nicardipine (25 mg) must be diluted before infusion by adding to 240 mL of suitable diluent to achieve a final concentration of 0.1 mg/mL. Titrate to desired effect.(3,5) More concentrated solutions (0.5 mg/mL) have been used in volume-restricted patients,(9,12,15) but thrombophlebitis has occurred.(12,15) A concentration of 3.6 mg/mL has been infused safely via a central line.(15)

Other routes of No information is available to support administration by other routes. administration

Comments Significant adverse effects: May cause tachycardia,(11,18,19) which has been treated with propranolol.(11) One report describes the sudden drop in blood pressure in two of four severely asphyxiated term neonates; hence, it should be used cautiously in asphyxiated patients and blood pressure should be carefully monitored.(28) Drug interactions: Consult appropriate resources for dosing recommendations before combining any drug with nicardipine. Nicardipine may be associated with drug interactions, including cyclosporine (increased cyclosporine concentrations), beta-blockers, cimetidine, and fentanyl.(3) Monitoring: Continuously monitor BP, HR (may cause reflex tachycardia), and infusion site for signs or symptoms of infiltration or thrombophlebitis.

REFERENCES 1. Institute for Safe Medication Practices. List of confused drug names. https://www.ismp.org/recommendations/confused-drug-names-list. Accessed January 25, 2016. 2. Hicks RW, Becker SC, Cousins DD, eds. MEDMARX Data Report. A Report on the Relationship of Drug Names and Medication Errors in Response to the Institute of Medicine’s Call for Action. Rockville, MD: USP Center for the Advancement of Patient Safety; 2008.  649