Intravenous nicardipine for the treatment of severe hypertension

Risk factors for clinically important traumatic brain injury in minor head injury in older people

BACKGROUND AND OBJECTIVES

The incidence of traumatic brain injury (TBI) in older individuals is increasing with an increase in the older population. For older people, the required medical interventions and hospitalization following minor head injury have negative impacts, which have not been reported in literature up till now. We aimed to investigate the risk factors for clinically important traumatic brain injury (ciTBI) in older patients with minor head injury.

METHODS

This is a retrospective single-center cohort study. Older patients aged ≥65 years presenting with head injury and a Glasgow Coma Scale (GCS) score of ≥13 upon arrival at the hospital between January 1, 2018, and October 31, 2021, were included. Patients with an injury duration of ≥24 h were excluded. The primary outcome was defined as ciTBI (including death, surgery, intubation, medical interventions, and hospital stays of ≥2 nights). Multiple logistic regression analysis was conducted to identify the risk factors.

RESULTS

A total of 296 patients were included initially, and 6 of them were excluded subsequently. ciTBI was identified in 62 cases. According to the results of the multiple logistic regression analysis, GCS scores of ≤14 (OR 3.72, 95% CI 1.89-7.30), high-risk mechanisms of injury (OR 2.80, 95% CI 1.39-5.64), vomiting (OR 5.01, 95% CI 1.19-21.1), and retrograde amnesia (OR 6.90, 95% CI 3.37-14.1) were identified as risk factors.

CONCLUSION

In older patients with minor head injury, GCS ≤14, high-risk mechanisms of injury, vomiting, and retrograde amnesia are risk factors for ciTBI.

Gasserian ganglion radiofrequency thermoablation in a patient with aneurysm of the anterior communicating artery -A case report

Background

Gasserian ganglion radiofrequency thermoablation is a good treatment option for the management of pain in trigeminal neuralgia. We report a case in which the patient of trigeminal neuralgia combined with anterior cerebral artery aneurysm was treated successfully by gasserian ganglion thermoablation without any complication.

Case

An 85-year-old female presenting with electric shock like sensation in the gum and molar teeth was diagnosed as trigeminal neuralgia. Carbamazepine medication and trigeminal nerve blockade relieved her pain partially, but severe side effects of carbamazepine occurred. Magnetic resonance angiography of the brain showed saccular aneurysm in inferior aspect of the anterior communicating artery. Gasserian ganglion thermoablation under sedation anesthesia using nicardipine was performed carefully without any rupture of the cerebral aneurysm.

Conclusions

Gasserian ganglion thermoablation could be performed safely in a patient with cerebral aneurysm without any inadvertent event.

Synthesis, Cytotoxicity and Molecular Docking Simulation of Novel bis-1,4-Dihydropyridines Linked to Aliphatic or Arene Core via Amide or Ester-Amide Linkages

OBJECTIVE

Novel bis(1,4-dihydropyridine-3,5-dicarbonitrile) derivatives linked to aliphatic or aromatic cores via amide or ester-amide linkages were prepared and their structures were confirmed by several spectral tools.

METHODS

The synthesis of novel N,N'-(alkanediyl)bis(2-(2-(3,5-dicyano-2,6-dimethyl-1,4-dihydropyridin- 4-yl)phenoxy)acetamide) by acid-catalyzed condensation of the bis-aldehydes with four equivalents of 3-aminocrotononitrile was reported.

RESULTS

The structures of the synthesized compounds were confirmed by different spectral tools. The molecular docking stimulation studies indicated that the prepared compounds bind to the active site of cellular inhibitor apoptotic protein (cIAP1-BIR3). MTT assay for the novel bis(1,4-dihydropyridines) was performed on two different human cell lines (A549 and HCT116).

CONCLUSION

Compound 5a showed higher cytotoxic activity against A549. Compound 5d showed moderate activity against HCT116. The rest of compounds indicated lower or no activity against both cell lines.

Management of hypertensive crises in the elderly

Hypertensive crises are elevations of blood pressure higher than 180/120 mmHg. These can be urgent or emergent, depending on the presence of end organ damage. The clinical presentation of hypertensive crises is quite variable in elderly patients, and clinicians must be suspicious of non-specific symptoms. Managing hypertensive crises in elderly patients needs meticulous knowledge of the pathophysiological changes in them, pharmacological options, pharmacokinetics of the medications used, their side effects, and their interactions with other medications. Clevidipine, nicardipine, labetalol, esmolol, and fenoldopam are among the preferred choices in the elderly due to their efficacy and tolerability. Nitroprusside, hydralazine, and nifedipine should be avoided, unless there are no other options available, due to the high risk of complications and unpredictable responses.

Synthesis, characterization and antitumor activity of novel tetrapodal 1,4-dihydropyridines: p53 induction, cell cycle arrest and low damage effect on normal cells induced by genotoxic factor H2O2

Synthesis of novel tetrakis(2,6-dimethyl-4-phenyl-1,4-dihydropyridinyl)methanes5a–dby acid-catalyzed condensation of the tetrakis-aldehydes6a–dwith eight equivalents of 3-aminobut-2-enenitrile2is reported. Antitumor activities of compounds5a–dwere also investigated.

The management of acute hypertension in patients with renal dysfunction: labetalol or nicardipine?

STUDY OBJECTIVES

To compare the safety and efficacy of U.S. Food and Drug Administration (FDA)-recommended doses of labetalol and nicardipine for hypertension (HTN) management in a subset of patients with renal dysfunction (RD).

DESIGN

Randomized, open label, multicenter prospective clinical trial.

SETTING

Thirteen United States tertiary care emergency departments.

PATIENTS OR PARTICIPANTS

Subgroup analysis of the Evaluation of IV Cardene (Nicardipine) and Labetalol Use in the Emergency Department (CLUE) clinical trial. The subjects were 104 patients with RD (i.e., creatinine clearance < 75 mL/min) who presented to the emergency department with a systolic blood pressure (SBP) ≥ 180 mmHg on 2 consecutive readings and for whom the emergency physician felt intravenous antihypertensive therapy was desirable.

INTERVENTIONS

The FDA recommended doses of either labetalol or nicardipine for HTN management.

MEASUREMENTS

The number of patients achieving the physician's predefined target SBP range within 30 minutes of treatment.

RESULTS

Patients treated with nicardipine were within target range more often than those receiving labetalol (92% vs. 78%, P = 0.046). On 6 SBP measures, patients treated with nicardipine were more likely to achieve the target range on either 5 or all 6 readings than were patients treated with labetalol (46% vs. 25%, P = 0.024). Labetalol patients were more likely to require rescue medication (27% vs. 17%, P = 0.020). Adverse events thought to be related to either treatment group were not reported in the 30-minute active study period, and patients had slower heart rates at all time points after 5 minutes (P < 0.01).

CONCLUSIONS

In severe HTN with RD, nicardipine-treated patients are more likely to reach a target blood pressure range within 30 minutes than are patients receiving labetalol.

CLINICAL IMPLICATIONS

Within 30 minutes of administration, nicardipine is more efficacious than labetalol for acute blood pressure control in patients with RD.

Intravenous nicardipine and labetalol use in hypertensive patients with signs or symptoms suggestive of end-organ damage in the emergency department: a subgroup analysis of the CLUE trial

OBJECTIVE

To compare the efficacy of Food and Drug Administration recommended dosing of nicardipine versus labetalol for the management of hypertensive patients with signs and/or symptoms (S/S) suggestive of end-organ damage (EOD).

DESIGN

Secondary analysis of the multicentre prospective, randomised CLUE trial.

SETTING

13 academic emergency departments in the USA.

PARTICIPANTS

Eligible patients had two systolic blood pressure (SBP) measures ≥180 mm Hg at least 10 min apart, no contraindications to nicardipine or labetalol and predefined S/S suggestive of EOD on arrival.

INTERVENTIONS

Medications were administered by continuous infusion (nicardipine) or repeat intravenous bolus (labetalol) for a study period of 30 min or until a specified target SBP ±20 mm Hg was achieved.

PRIMARY OUTCOME MEASURE

Percentage of participants achieving a predefined target SBP range (TR) defined as an SBP within ±20 mm Hg as established by the treating physician.

RESULTS

Of the 141 eligible patients, 49.6% received nicardipine, 51.7% were women and 81.6% were black. Mean age was 52.2±13.9 years. Median initial SBP did not differ in the nicardipine (210.5 (IQR 197-226) mm Hg) and labetalol (210 (200-226) mm Hg) groups (p=0.862). Nicardipine patients were more likely to have a history of diabetes (41.4% vs 25.7%, p=0.05) but there were no other historical, demographic or laboratory differences between groups. Within 30 min, nicardipine patients more often reached the target SBP range than those receiving labetalol (91.4% vs 76.1%, difference=15.3% (95% CI 3.5% to 27.3%); p=0.01). On multivariable modelling with adjustment for gender and clinical site, nicardipine patients were more likely to be in TR by 30 min than patients receiving labetalol (OR 3.65, 95% CI 1.31 to 10.18, C statistic=0.72).

CONCLUSIONS

In the setting of hypertension with suspected EOD, patients treated with nicardipine are more likely to reach prespecified SBP targets within 30 min than patients receiving labetalol.

CLINICAL TRIAL REGISTRATION

NCT00765648, clinicaltrials.gov.

Intravenous use of the calcium-channel blocker nicardipine as second-line treatment in severe, early-onset pre-eclamptic patients

OBJECTIVE

To evaluate the efficacy of intravenous administration of nicardipine as a second-line temporizing treatment in severe, early-onset, pre-eclamptic patients.

DESIGN

An open, prospective, evaluation study.

SETTING

A high-care obstetric ward in a tertiary care centre.

PATIENTS

Twenty-seven early-onset, pre-eclamptic patients with a median gestational age of 27 weeks 1 day (range, 21 weeks 2 days-32 weeks 4 days) with treatment failure on standard intravenous antihypertensive drugs (ketanserin, dihydralazin or labetalol).

INTERVENTION

Nicardipine infusion was started for temporizing management of pre-eclampsia at a dosage of 3 mg/h and was subsequently titrated according to blood pressure. Nicardipine treatment was continued for as long as the maternal and foetal conditions allowed.

MAIN OUTCOME MEASURES

The endpoints of the study were defined as the percentage of patients reaching the target diastolic intra-arterial blood pressure (< 100 mmHg or < 90 mmHg in Haemolysis, Elevated Liver Enzymes, Low Platelet Count syndrome patients) within 1 h after the start of treatment, and the number of days of prolongation of pregnancy under nicardipine treatment. Maternal and foetal side effects, foetal death and neonatal outcome were assessed.

RESULTS

In all patients the target diastolic intra-arterial blood pressure was obtained within a median of 23 min (range, 5-60 min). Delivery was postponed for a median of 4.7 days (range, 1-26 days) using nicardipine treatment, in a maximum dosage ranging from 3 to 9 mg/h. Detailed haemodynamic parameters with corresponding nicardipine dosages were obtained in nine patients. In one-fifth of the patients, unwanted hypotensive periods were registered during treatment, manageable with dosage adaptation. Foetal well-being did not seem adversely affected.

CONCLUSION

This evaluation shows that nicardipine is a potent antihypertensive drug and can be used for temporizing management in severe, early-onset pre-eclampsia when other antihypertensive drugs have failed.

Nicardipine versus Nitroprusside Infusion as Antihypertensive Therapy in Hypertensive Emergencies

This prospective study compared the efficacy of nicardipine and nitroprusside for treating hypertensive emergencies by measuring haemodynamic indices and serum catecholamine levels. Patients admitted to the emergency department with a hypertensive crisis and acute pulmonary oedema received intravenous infusions of nitroprusside (starting dose 1 μg/kg per min, n = 20) or nicardipine (starting dose 3 μg/kg per min, n = 20). Both groups experienced significant declines in systolic and diastolic blood pressure after treatment, but there were no significant time-dependent differences between the groups. Heart rate decreased in the nicardipine group and increased in the nitroprusside group, but neither change was significant. Respiration rate decreased and capillary oxygen saturation rate increased after treatment in both groups. Adrenaline and noradrenaline levels decreased significantly after treatment in both groups; noradrenaline levels were significantly decreased in the nicardipine-treated group compared with the nitroprusside-treated group. Injectable nicardipine is easy to use and as effective as nitroprusside for treating hypertensive crisis with acute pulmonary oedema.

Resistant hypertension, secondary hypertension, and hypertensive crises

Resistant hypertension, secondary hypertension, and hypertensive crises are uncommon but potentially dangerous forms of hypertension that are associated with an increased risk of complications such as myocardial infarction, heart failure, stroke, and renal failure. Appropriate diagnostic screening and selective drug or surgical management can reduce the risk of these complications dramatically. In compliant patients, resistant hypertension occurs most often in obese patients receiving inadequate diuretic therapy. In patients with clinical clues to the diagnosis, the best current screening test for renovascular hypertension is probably the ACE-inhibitor renal scintiscan. Angioplasty is considerably more successful in younger patients with fibrous dysplasia than in older patients with the atherosclerotic variety. Hypertensive crises are divided into BP urgencies and emergencies. In both settings, the reduction in BP should generally be gradual rather than abrupt, with no intent to acutely normalize the BP.

Intravenous nicardipine for treatment of severe hypertension in children

OBJECTIVE

To examine the effect of intravenous nicardipine in the treatment of children with severe hypertension.

METHODS

The medical records of 29 children (mean age 94 months) treated with intravenous nicardipine were retrospectively reviewed. The mean duration of severe hypertension before nicardipine use was 12.5 hours. Most (74%) patients were receiving other antihypertensive agents before nicardipine.

RESULTS

The initial nicardipine dose was 0.8 +/- 0.3 microg/kg/min (mean +/- SD). The mean effective dose was 1.8 +/- 1.0 microg/kg/min (range, 0.3 to 4.0). Blood pressure control was achieved within 2.7 +/- 2.1 hours after nicardipine was started. Nicardipine treatment produced a 16% reduction in systolic blood pressure, a 23% reduction in diastolic blood pressure, and a 7% increase in heart rate. Nicardipine was effective as a single agent on 26 (84%) of 31 occasions. Adverse effects included tachycardia, flushing, palpitations, and hypotension.

CONCLUSIONS

When administered in the intensive care unit setting with close patient monitoring, intravenous nicardipine effectively lowered blood pressure in children with severe hypertension. Larger prospective studies should be conducted to confirm these findings.

Treatment of hypertension in the perioperative patient

OBJECTIVE

To review studies and drug therapy relating to the treatment of hypertension in perioperative patients.

DATA SOURCES

Articles were selected from a MEDLINE search (1966-August 1998), and several textbooks on hypertension and surgery were reviewed. In addition, bibliographies of all articles and textbook chapters were studied for articles not found in the computerized searches.

STUDY SELECTION

Clinical studies involving hypertension in the perioperative setting were included. The initial search was limited to studies conducted in humans and published in English.

DATA EXTRACTION

Information regarding drug therapy was reviewed and guidelines were constructed for managing surgical patients with acute blood pressure elevations.

DATA SYNTHESIS

Although nitroprusside and nitroglycerin, with their short onset of action and duration of effect, are indicated for hypertensive emergencies, a variety of agents are available for hypertensive urgencies. An algorithm that can be used as a template for the development of intrainstitutional guidelines is provided.

CONCLUSIONS

Due to the scarcity of comparative trials, decisions involving agents for the treatment of perioperative hypertension must often be made based on combined efficacy, toxicity, cost, and convenience considerations.

Heart rate and blood pressure power spectral analysis during calcium channel blocker induced hypotension

PURPOSE

To observe heart rate (HRV) and blood pressure variability (BPV) as indices of neurocirculatory responses to induced hypotension with diltiazem and/or nicardipine for hip surgery.

METHODS

Thirty-six ASA I-II patients received diltiazem (group D, n = 12), nicardipine (group N, n = 12) or combination of diltiazem/nicardipine (group DN, n = 12). The intensity of HRV and BPV, was determined by spectral analysis of HRV and BPV before anesthesia (T0), just before induced hypotension (T1), and at 10 and 30 min after the start of induced hypotension (T2 and T3, respectively). The logarithmic HRV and BPV were integrated: sympathetic and parasympathetic mediated low frequency area (0.06-0.1 Hz, LF), parasympathetic related high frequency area (0.15-0.4 Hz, HF) and total frequency area (0.01-0.4 Hz). Blood loss was assessed by weighing gauzes and measuring suction.

RESULTS

Group DN had less blood loss (466 +/- 46 ml, mean +/- SEM) than group D (733 +/- 100 ml, P < 0.05). Diltiazem (11.4 +/- 0.9 microg x kg(-1) x min(-1)), and combination of diltiazem (0.25 +/- 0.01 mg x kg(-1)) and nicardipine (5.9 +/- 0.9 microg x kg(-1) x min(-1)) decreased LF-HRV at T2 and T3 (P < 0.05 vs T0 and T1), while nicardipine (8.1 +/- 0.8 microg x kg(-1) x min(-1)) showed increase in LF-HRV at T2 (P < 0.05 vs T1). HF-HRV unchanged through hypotension except for a decrease in group N at T3 (P < 0.05 vs T1). There were no increases in HF-BPV, and LF-BPV, except for a diltiazem induced decrease in LF-BPV at T3 (P < 0.05 vs T0 and T1).

CONCLUSION

Group D and group DN can be used for deliberate hypotension without an increase in sympathetically mediated LF-HRV.

Formulation of controlled release microspheres containing nicardipine: the role of pharmacokinetic modeling and computer simulation

Nicardipine is an antihypertensive drug of the dihydropyridine series. It has high solubility in an acidic and low solubility in an alkaline medium. It is rapidly absorbed, extensively presystemically metabolized and excreted in the urine and faeces, mainly as inactive metabolites. Since the duration of its action can be extended by prolonging the absorption interval, the design of controlled release formulation is reasonable. The aim of the present study was to prepare microspheres which would release nicardipine at a decreased rate in gastric and increased rate in intestinal juice during a 12 h interval. Pharmacokinetic modeling based on compartment analysis and supported by analog computer and digital simulation technique showed that the target steady state peak plasma concentrations of 32 microg/l and trough plasma concentration of 7 microg/l would be maintained if nicardipine were incorporated in a formulation releasing the drug as follows: 25% after 1 h, 40% after 2 h, 65% after 4 h, 80% after 6 h, 90% after 8 h and 100% by 12 h. Microspheres have been prepared from hydroxypropylmethylcellulose phthalate polymer using the solvent evaporation method. Drug content, scanning electron micrographs, particle size distribution and dissolution profile were determined. In vitro nicardipine release was described by a biphasic square root of time kinetics and was in accordance with the above values relating to the dissolution. Furthermore, a composed first-pass pharmacokinetic model with derived release function as an input was developed to predict nicardipine plasma concentrations after single- and 12 h multiple-dosage-regimen scheme administration of controlled release microspheres.

Nicardipine versus salbutamol in the treatment of premature labor. A prospective randomized study

OBJECTIVE

To compare the tocolytic action and the side effects of nicardipine to those of salbutamol in patients presenting premature labor in order to propose nicardipine as a promising alternative to salbutamol in the treatment of premature labor.

STUDY DESIGN

Ninety patients admitted to the Saint-Antoine Hospital (Paris, France) for premature labor were included in this prospective randomized open study comparing nicardipine and salbutamol. Each study group included 45 patients.

RESULTS

The mean term of delivery in the nicardipine group was 38.4 +/- 1.7 and 37.6 +/- 2.1 weeks in the salbutamol group (P < 0.05). The percentage of deliveries after 37 gestational weeks was higher with nicardipine (P < 0.05). The birthweight of infants was 3131 +/- 488 g with patients treated with nicardipine and 3019 +/- 494 g with the salbutamol group (NS). The Apgar scores were identical in the two groups at 1 and 5 min. There was no statistically significant difference in the number of neonates admitted into intensive care nor the premature infant center between the two groups. Nicardipine reduced the systolic and diastolic blood pressure whereas there was no change in the salbutamol group. Maternal pulse rate was significantly increased in the salbutamol group (P < 0.01) and was unchanged in the nicardipine group. The most common side-effects with nicardipine were headaches, and with salbutamol, tremors and palpitations.

CONCLUSIONS

Nicardipine is a tocolytic agent as effective as salbutamol in the treatment of premature labor. The use of nicardipine is an interesting alternative to salbutamol, especially in cases of hypertension, diabetes or maternal cardiopathy.

Human umbilical vessels: responses to agents frequently used in obstetric patients

OBJECTIVE

Our purpose was to study the effects of some drugs frequently used in pregnant women on isolated human umbilical artery and vein segments.

STUDY DESIGN

Umbilical artery and vein rings from normal term pregnancies were mounted in Krebs-bicarbonate solution in organ baths for isometric tension recording. Rings were contracted with potassium chloride (60 mmol/L) or U46619 (10(-8) mol/L) and then exposed to cumulative concentrations of nimodipine, nifedipine, nicardipine, phenytoin, magnesium sulfate, and hydralazine. Concentration-response curves were constructed by means of the difference in the percent relaxation between test and control vessels. Data analysis was by repeated measures analysis of variance, Newman-Keuls test, and the unpaired Student t test as appropriate. A value of p < 0.05 was considered statistically significant.

RESULTS

All the agents studied were effective umbilical vasodilators, except for hydralazine, which had minimal effect. The dihydropyridine calcium antagonists were more potent vasodilators than were the other agents studied. Nifedipine was the most potent calcium blocker and was the only dihydropyridine that relaxed the umbilical vein to a greater extent than the umbilical artery.

CONCLUSION

The most commonly used drugs in preeclampsia have variable effects on the umbilical vessels.

Intravenous nicardipine in hypertensive children

Fourteen hypertensive patients hospitalized in a paediatric intensive care unit were studied to evaluate safety and hypotensive efficacy of intravenous nicardipine. Systolic and diastolic blood pressure significantly decreased 1 h after the beginning of the treatment (1 microgram/kg per minute). Mean decrease in systolic blood pressure during the first 24 h was between 9.9% and 13.4% of the initial value. Mean lowering of diastolic blood pressure was between 16.7% and 25.6%. Nicardipine did not significantly affect heart rate with dose of 1 microgram/kg per minute. No clinical side-effects were observed. Nicardipine could be a first line drug for the treatment of hypertension in paediatric intensive care units.

Acute pharmacokinetic and hemodynamic effects of intravenous bolus dosing of nicardipine

The antihypertensive effects, duration of action, and pharmacokinetics of intravenous bolus doses of nicardipine were investigated in a series of patients with mild-to-moderate hypertension. Patients with a supine diastolic blood pressure between 95 and 114 mm Hg and a heart rate less than 90 beats/min who received no other antihypertensive medications were included in the study. On separate study days, single intravenous bolus doses of 0.125, 0.25, 0.5, 1, 3, 5, and 7 mg of nicardipine were administered over a 2-minute period. Blood pressure and heart rate were measured for 6 hours after an intravenous bolus of nicardipine was given, and serum nicardipine levels were measured throughout the study. Although the antihypertensive effect occurred immediately during the bolus infusion, peak average decreases in systolic and diastolic pressure ranged from 20 to 25 and 15 to 44 mm Hg, respectively, and occurred 2.5 +/- 0.6 minutes after infusion. Heart rate increased by 12 to 40 beats/min during the peak effect. The mean duration of action after an intravenous bolus dose was 24 +/- 5 minutes. A dose-response relationship was observed, as both nicardipine dosage and plasma nicardipine concentration correlated with reduction in blood pressure. These data indicate that bolus administration of nicardipine may provide a practical approach for the rapid parenteral treatment of hypertensive states.

Intravenous nicardipine hydrochloride: treatment of patients with severe hypertension

Nicardipine hydrochloride, a dihydropyridine calcium entry-blocking drug, was administered to 66 patients with severe hypertension during three protocols designed to examine the efficacy and safety of this investigation drug. It was shown that nicardipine was uniformly effective in lowering blood pressure to a therapeutic goal of 95 mm Hg. Time to achieve therapeutic effect was dose dependent, and steady-state blood levels were achieved after 8 to 12 hours. Reductions in both systolic and diastolic blood pressure but not changes in heart rate were correlated with plasma concentrations of nicardipine. In dose-ranging studies, the minimal effective dose of nicardipine appeared to be 2 mg/hr; 1 mg/hr was an ineffective dose, and little additional effect was seen above 4 mg/hr. Side effects were modest and consisted of those associated with vasodilation--headache, flushing, and feelings of warmth. In the initial group of patients studied, local thrombophlebitis occurred in a substantial number of patients. This was seen only after 14 hours of infusion. In subsequent studies, the infusion site was changed after 12 hours, and no further cases of thrombophlebitis were seen. Nicardipine appears to be therapeutic agent for parenteral use that shows promise in the treatment of severe hypertension.