Bedside Snapshot
  • Core Use: Rapid, titratable blood pressure control in hypertensive emergencies and perioperative/ICU settings
  • Mechanism: Pure arterial vasodilator that decreases SVR and afterload with minimal effect on heart rate
  • Onset/Duration: BP responds within 2–4 minutes; ultra-short context-insensitive half-life of ~1 minute; BP returns toward baseline within 5–15 minutes after stopping
  • Typical Dose: 1–21 mg/hr IV infusion (0.5 mg/mL concentration); start at 1–2 mg/hr and titrate every 90 seconds to 5 minutes
  • Key Danger: Hypotension, reflex tachycardia; contraindicated in soy/egg allergy and defective lipid metabolism
  • Special Note: Lipid emulsion vehicle (like propofol) provides ~2 kcal/mL; consider combined lipid load with propofol or TPN
Brand & Generic Names
  • Generic Name: Clevidipine butyrate
  • Brand Names: Cleviprex
Medication Class

Ultra-short-acting dihydropyridine calcium channel blocker (CCB); IV arterial vasodilator

Pharmacology

Mechanism of Action:

  • Dihydropyridine calcium channel blocker that selectively inhibits L-type calcium channels in arteriolar smooth muscle
  • Reduces calcium influx → arterial vasodilation in systemic and coronary arteries → decreased SVR and afterload, reduced BP
  • Minimal direct effect on venous capacitance vessels and cardiac conduction; does not significantly depress myocardial contractility at usual doses
  • Ultra-short action is due to rapid ester hydrolysis by blood and tissue esterases, not organ-dependent clearance

Pharmacokinetics:

  • Onset: BP reduction within 2–4 minutes of starting or adjusting infusion
  • Peak Effect: Near steady state within ~10 minutes of a rate change
  • Distribution: High protein binding; confined largely to intravascular/lipid phase during infusion
  • Metabolism: Rapid ester hydrolysis by blood and tissue esterases to inactive metabolites; not dependent on liver or kidney function
  • Elimination: Context-insensitive half-life ~1 minute; effect rapidly dissipates after stopping infusion (BP returns toward baseline within ~5–15 minutes)
Indications
  • Short-term treatment of hypertension when oral therapy is not feasible and rapid, fine-tunable control is required
  • Hypertensive emergencies, especially perioperative and neurocritical care (e.g., ICH, SAH, post-thrombectomy BP targets) where tight control is needed
  • Alternative to nicardipine when very rapid titration is desired or when volume of infusion is a concern (clevidipine is more concentrated)
  • Controlled hypotension during surgery in select cases per anesthesia protocols
Dosing & Administration

Available Forms:

  • Ready-to-use lipid emulsion: 50 mL or 100 mL vials containing 0.5 mg/mL clevidipine (e.g., 25 mg/50 mL or 50 mg/100 mL)
  • Administer undiluted using a dedicated line when possible; use a vented IV set and infusion pump
  • Lipid emulsion provides ~2 kcal/mL and has the same contamination/infection precautions as propofol (tubing change intervals, etc.)

Adult Dosing (IV Infusion):

Step Dose (mg/hr) Approx mL/hr (0.5 mg/mL) Notes
Starting dose 1–2 mg/hr 2–4 mL/hr Start at low end in elderly or volume-depleted patients
Titration increments Double q90 sec–5 min initially E.g., 2 → 4 → 8 mg/hr Frequent BP checks; slow down as you approach goal
Typical effective range 4–12 mg/hr 8–24 mL/hr Most patients controlled in this range
Maximum recommended dose 21 mg/hr 42 mL/hr Above this, additional benefit is unlikely and risk increases
Elderly, frail, or very labile BP Start 0.5–1 mg/hr 1–2 mL/hr Use smaller, slower titrations
Maximum duration (per label) Not well studied >72 hours; in practice, often used short term until PO agents established
Contraindications

Absolute Contraindications:

  • Allergy to soybeans, soy products, eggs, or egg products (due to lipid emulsion components)
  • Defective lipid metabolism (e.g., pathologic hyperlipidemia, lipoid nephrosis, acute pancreatitis if associated with hyperlipidemia)
  • Severe aortic stenosis: vasodilation can precipitate profound hypotension and ischemia by reducing coronary perfusion pressure
  • Known hypersensitivity to clevidipine or any component of the formulation

Major Precautions:

  • Use caution in patients with heart failure or impaired LV function—afterload reduction can help, but excessive vasodilation may drop BP too far
  • Monitor serum triglycerides if prolonged use or concurrent propofol/other lipids (risk of hypertriglyceridemia, pancreatitis)
  • Because of rapid onset/offset, avoid overshooting: make small dose adjustments as you approach target BP
  • Avoid use in patients who cannot tolerate even brief episodes of hypotension (e.g., critical coronary stenosis, large-vessel occlusion pre-thrombectomy)
Lipid Emulsion Warning: Clevidipine contains egg and soy components. Screen for allergies before administration. Monitor combined lipid load when used with propofol or TPN.
Adverse Effects

Common:

  • Hypotension
  • Reflex tachycardia or palpitations
  • Headache
  • Nausea

Serious:

  • Severe hypotension requiring vasopressors or fluid resuscitation
  • Myocardial ischemia or infarction in patients with critical coronary disease due to drop in diastolic pressure
  • Atrial fibrillation or other supraventricular arrhythmias (less common)
  • Hypertriglyceridemia and pancreatitis with prolonged or high-dose use (theoretic/rare, but lipid load is cumulative)
  • Allergic reactions to components of the lipid emulsion
Special Populations

Elderly Patients:

  • Start at lower doses (0.5–1 mg/hr) and titrate more slowly due to increased sensitivity to vasodilation
  • Higher risk of hypotension and falls

Renal Impairment:

  • No dose adjustment required; clevidipine is not dependent on renal elimination

Hepatic Impairment:

  • No dose adjustment required; metabolism occurs via blood and tissue esterases, not hepatic enzymes

Pregnancy:

  • Category C: Use only if potential benefit justifies potential risk to fetus
  • Limited human data; animal studies show adverse effects

Lactation:

  • Unknown if excreted in breast milk; use caution
Monitoring

Clinical Monitoring:

  • Continuous noninvasive or invasive arterial blood pressure monitoring, especially during titration
  • Heart rate and rhythm for reflex tachycardia or arrhythmias
  • Neurologic status in neuro patients where overcorrection of BP may risk ischemia

Laboratory Monitoring:

  • Serum triglycerides and lipase if prolonged therapy or if also receiving propofol or TPN lipids
  • Total daily lipid load when combined with propofol or parenteral nutrition
Clinical Pearls
Clevidipine vs. Nicardipine: Clevidipine and nicardipine fill a similar niche; clevidipine is faster on/faster off, while nicardipine may be more familiar and cheaper in some systems. Ideal for situations where BP targets change rapidly (e.g., pre- vs post-clot retrieval, dynamic neuro targets).
Lipid Load Consideration: Because of its lipid vehicle, think about combined lipid load if the patient is also on propofol or TPN—especially in pancreatitis or hypertriglyceridemia.
Aortic Stenosis Warning: In aortic stenosis or fixed obstruction, any potent vasodilator (including clevidipine) can be dangerous—opt for agents that reduce HR and BP more gently (e.g., esmolol in dissection with AS).
Titration Strategy: Start low and go slow in elderly or volume-depleted patients. Make frequent small adjustments rather than large jumps to avoid overshoot. The ultra-short half-life allows for rapid corrections if BP drops too low.
Infusion Pearls: Use a vented IV set and dedicated line when possible. Change tubing per institutional protocol (similar to propofol guidelines). The 0.5 mg/mL concentration makes dose calculations straightforward: mg/hr × 2 = mL/hr.
References
  • 1. Lexicomp. (2024). Clevidipine: Drug information. Wolters Kluwer.
  • 2. Pollack, C. V., Varon, J., & Garrison, N. A. (2009). Clevidipine: A novel intravenous antihypertensive agent for the treatment of acute hypertension. American Journal of Emergency Medicine, 27(8), 1007–1014. https://doi.org/10.1016/j.ajem.2009.04.020
  • 3. Chiesi USA. (2022). Cleviprex (clevidipine) injection, emulsion [Package insert].
  • 4. Peacock, W. F., Hilleman, D. E., Levy, P. D., Rhoney, D. H., & Varon, J. (2012). A systematic review of nicardipine vs labetalol for the management of hypertensive crises. American Journal of Emergency Medicine, 30(6), 981–993. https://doi.org/10.1016/j.ajem.2011.06.003
  • 5. Aronson, S., Dyke, C. M., Stierer, K. A., Levy, J. H., Cheung, A. T., Lumb, P. D., Kereiakes, D. J., & Newman, M. F. (2008). The ECLIPSE trials: Comparative studies of clevidipine to nitroglycerin, sodium nitroprusside, and nicardipine for acute hypertension treatment in cardiac surgery patients. Anesthesia & Analgesia, 107(4), 1110–1121. https://doi.org/10.1213/ane.0b013e31818240db
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