A 38 y/o male patient presents to the clinic with a chief complaint of headache. His vitals are HR 90, BP= 190/115, resp= 24. The intern does a routine physical exam and found nothing – no end organ damage. The patient has no allergies nor any other significant medical history. The student wants to treat this elevated blood pressure with sublingual
nifedipine 10mg.

Do you concur or not? Why or why not?

SELECT  here for discussion

NO!!!!! We’ve seen a slight increase in orders for this medication for this use by this route recently and I wanted to re-emphasize this point.

Some definitions:

Hypertensive emergencies – a blood pressure greater than 180/110 accompanied by end organ damage (encephalopathy, intracranial hemorrhage, acute LVH with pulmonary edema, etc). Requires immediate (i.e. minutes to hours) but gradual reduction of blood pressure, usually with intravenous agents.

Hypertensive urgencies – same as above but without end organ damage. Blood pressure reduction should be accomplished gradually (i.e. several hours to days).

Sublingual nifedipine was originally thought to be a safe and effective method for lowering blood pressure in patients with a hypertensive urgency. The thought was sublingual administration provided a more rapid absorption into the systemic circulation and a more rapid correction of the hypertensive urgency. Studies determined the nifedipine, even with sublingual administration, is mostly absorbed from swallowing and absorbing the drug via the gastric mucosa.  Rapid lowering of blood pressure can be especially detrimental/ harmful in elderly patients. Some elderly patients have a higher than normal blood pressure in order to perfuse their vital organs. The higher BP may be necessary to get blood and oxygen to all the organs through atherosclerotic vessels. Reducing the pressure significantly may halt blood flow to these organs.

There were more than a few cases of very bad outcomes, to include MI, stroke, and death, in hypertensive patients treated with sublingual nifedipine. See the following statement out of JAMA:

(Reference: JAMA 1996;276:1328-31.)

Should a moratorium be placed on sublingual nifedipine capsules for hypertensive emergencies and pseudoemergencies?

“Over the past 2 decades, nifedipine in the form of capsules has become widely popular in the treatment of hypertensive emergencies.  Unlike other agents, such as sodium nitroprusside, nicardipine hydrochloride, diazoxide, and nitroglycerin—which require intravenous administration and monitoring of blood pressure—nifedipine can be given orally, and close monitoring is said not to be necessary. Although administration of nifedipine capsules has been reported to be expedient and safe, it has not been approved by the Food and Drug Administration for labeling for treatment of hypertensive emergencies or of any other form of hypertension because of lack of outcome data. A review of the literature revealed reports of serious adverse effects such as cerebrovascular ischemia, stroke, numerous instances of severe hypotension, acute myocardial infarction, conduction disturbances, fetal distress, and death. Sublingual absorption of nifedipine has been found to be poor; most of the drug is absorbed by the intestinal mucosa. Given the seriousness of the reported adverse events and the lack of any clinical documentation attesting to a benefit, the use of nifedipine capsules for hypertensive emergencies and pseudo-emergencies should be abandoned.”

Bottom line – don’t use sublingual nifedipine to treat hypertensive urgencies or emergencies. Other oral medications available and effective for treating hypertensive urgencies include:

Clonidine 0.2mg P.O. every hour until blood pressure controlled or a total dose of 0.7mg is reached

Captopril 25-50mg P.O. at 1-2 hour intervals as needed to control BP

Labetolol 200-300mg P.O. every 2-3 hours as needed to control BP

This Pearl is meant for academic and educational purposes only. This Pearl is meant to raise important points regarding the safe and cost-effective pharmacotherapy of patients. It is not meant to be the definitive reference for the treatment or prophylaxis of various diseases. Although every effort is taken to ensure this Pearl is correct and factual, errors may occur. The Pharmacoeconomic Center assumes no liability for incorrect information or harm that may occur from the use of the information included in this Pearl.