Recommendations: MEC approved

• Immediate release nifedipine capsules will be removed from formulary due to availability of safer agents and revised package labeling
• For hypertensive urgencies, consider use of oral captopril or labetalol
• For angina, consider use of long-acting nifedipine or verapamil or diltiazem

Findings:

• Revised package insert from 9/2000 states in boldface print, capsules should not be used for the acute reduction of blood pressure or for the control of essential hypertension also they should be avoided in the setting of acute coronary syndrome (when infarction may be imminent) and should not be administered for 1 week after myocardial infarction.
• Not approved by FDA for hypertensive emergencies or any other form of hypertension due to lack of outcome data. Approved for angina only.
• Well documented reports describe profound hypotension, myocardial infarction, hemiparesis, and death when immediate release capsules are used (see table below)
• Hypertensive emergencies require immediate blood pressure reduction within 30 minutes of initiating therapy in order to prevent or limit target organ damage. The goal is to decrease BP by no more than 25% initially. Nitroprusside, in many cases, is usually the drug of choice
• Elevated blood pressure alone, in the absence of symptoms, rarely requires emergency therapy
• Hypertensive urgencies require blood pressure reduction over 24 hours. The patient will usually be asymptomatic or mildly to moderately symptomatic and the diastolic blood pressure will be > or = 120mm Hg. Drugs of choice according to JNC-VI include loop diuretics, beta-blockers, or ACE inhibitors.

References:

-Grossman E, Messerli FH, Grodzicki T et al: Should a moratorium be placed on sublingual nifedipine capsules given for hypertensive emergencies and pseudoemergencies? JAMA 1996;276:1328-31.

-The sixth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). Arch Intern Med 1997;157:2413-46.

-Procardia package insert. Pfizer. Revised 9/2000.