Accelerated Hypertension Guidelines

Oral Agents

An excessive hypotensive response is potentially dangerous and can possibly lead to ischaemic complications such as stroke, MI or blindness in some cases. So in those who are severely hypertensive but asymptomatic, slower reductions in blood pressure should be provided with oral agents.

Blood should be measured at regular intervals in the sitting and standing positions. A postural drop of > 20mmHg suggests hypovolaemia which needs to be corrected.

Oral Agent Dosing Maximum Total Cautions Intervals Daily Dose 1st Line – Amlodipine 6 hourly 10mg 5mg 2nd Line- Metoprolol 1 hourly 400mg DO NOT USE IN 25mg PATIENTS WITH ASTHMA OR COPD

Note:  Use ACE inhibitors with caution as this can cause a rapid fall in blood pressure  Use diuretics with caution, unless there is clear evidence of volume overload

Intravenous agents

Where more rapid control is needed or when the patient cannot absorb oral preparations (e.g. post-operatively) or if NBM IV agents can be given.

A hypertensive crisis with evidence of end- organ damage should be treated as a critical emergency and should be treated in a level 2 environment (HDU/CCU)

1st Line: IV Agent Route Dose and Rate Diluent Additional Info Concentration Labetolol IV bolus 20mg (undiluted) 1 minute N/A Rapid onset of then every 10 (max rate action – 5 minutes. minutes 20- 50mg/minute) Do not use in 80mg if needed COPD or asthma. (Total daily dose 200mg) Labetolol IV Infusion 1mg/mL 2mg/minute Glucose Usual Total dose: 10% or 50-200mg. Do not NaCl use in COPD or 0.9% asthma.

If you encounter excessive bradycardia this can be countered with IV atropine sulphate 0.6-2.4mg in divided doses of 600micrograms.

2nd Line: IV Agent Route Dose and Rate Diluent Additional Info Concentration GTN IV infusion 1mg/mL 2- N/A (50mg/mL pre- 10mg/hour filled syringes)

Guideline Reviewed by: Hannah Beba- Specialist Clinical Pharmacist Date of Review: November 2013 Date for Renewal : November 2015 Always check BNF for contra-indication, cautions and dose reductions in renal/hepatic impairment before prescribing any of the above agents

Monitoring

Time ( from start of treatment) Monitoring intervals 0-30 minutes Every 5 minutes 30 minutes – 2 hours 30 minutes Every 30 minutes 2 hours 30 minutes – 8 hours 30 minutes Every hour

Guideline Reviewed by: Hannah Beba- Specialist Clinical Pharmacist Date of Review: November 2013 Date for Renewal : November 2015