Nicardipine (Cardene)

• Core dose: 5 mg/hr IV infusion; titrate by 2.5 mg/hr every 5–15 min to max 15 mg/hr; once at goal, may reduce to maintenance 3 mg/hr
• Onset/duration: Onset 5–15 min; offset 30–60 min after stopping; half-life ~14 hr (but clinical effect shorter due to redistribution)
• Key danger: Reflex tachycardia, hypotension, peripheral edema; avoid in severe aortic stenosis; extravasation can cause local irritation
• Special: Dihydropyridine CCB; cerebral-selective vasodilation makes it preferred for hypertensive emergencies with stroke/ICH; titratable and predictable BP response

• Generic Name: Nicardipine
• Brand Names: Cardene, Cardene IV, Cardene SR

Dihydropyridine calcium channel blocker (CCB) - Predominantly arteriolar vasodilator with minimal direct myocardial depression at standard doses.

Mechanism of Action:

• Blocks L-type voltage-gated calcium channels in vascular smooth muscle
• Produces preferential arteriolar vasodilation → decreases systemic vascular resistance (afterload) and blood pressure
• Causes coronary vasodilation and can improve coronary blood flow
• Minimal direct negative inotropy at usual doses, but reflex sympathetic activation may lead to tachycardia

Pharmacokinetics:

IV (Cardene IV):

• Route/Absorption: 100% systemic availability by IV infusion (no bolus recommended for adults)
• Onset: BP reduction within minutes after initiation
• Time to near-steady effect: ~45 minutes at a fixed rate
• Offset: About 50% loss of effect ~30 minutes after stopping the infusion; most effect gone by 30–60 minutes
• Distribution: Protein binding >95%; Large apparent volume of distribution (~8 L/kg)
• Metabolism: Extensive hepatic metabolism via CYP3A4 (also 2D6, 2C8, 2C19) to inactive metabolites
• Elimination: Terminal half-life ~8–14 hours (clinical effect much shorter); Metabolites excreted ~50–60% in urine, remainder in feces

Oral (IR/SR):

• Bioavailability: ~35% (first-pass metabolism)
• Tmax: ~0.5–2 hours
• Effective half-life: ~2–4 hours for BP effect; terminal ~8–9 hours

Educational only – follow current guidelines, institutional policies, and prescriber orders.

Primary IV indications (short-term use):

• Short-term treatment of hypertension when oral therapy is not feasible (FDA-labeled indication)
• Hypertensive emergency, especially:
  • Acute ischemic stroke when BP lowering is indicated (e.g., pre/post thrombolysis or thrombectomy)
  • Intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) where tight BP control is important
  • Peri-operative hypertension and post-operative hypertension

Oral indications:

• Chronic hypertension
• Chronic stable angina

• Hypertensive emergency/elevated BP requiring IV therapy
• Acute ischemic stroke with BP above treatment thresholds (especially around thrombolysis or thrombectomy)
• Intracerebral hemorrhage and subarachnoid hemorrhage needing controlled BP reduction
• Peri-/post-operative hypertension
• Chronic hypertension and stable angina (oral formulations)

Dosing below is for education only. Always follow local protocols, prescriber orders, and institutional policies.

Available Forms:

• IV concentrate: 2.5 mg/mL (e.g., 10 mL vials/ampules) – must be diluted
• Premixed IV bags:
  • 20 mg in 200 mL (0.1 mg/mL)
  • 40 mg in 200 mL (0.2 mg/mL)
• Oral formulations:
  • Immediate-release capsules: 20 mg, 30 mg
  • Sustained-release (SR): 30 mg, 60 mg

IV Nicardipine Dosing – Hypertensive Emergency (Adult):

Continuous IV infusion:

• Initial rate: 5 mg/hr
• Titration: Increase by 2.5 mg/hr every 5–15 minutes until target BP achieved
• Usual maintenance range: 3–15 mg/hr
• Maximum: 15 mg/hr

Approximate oral → IV conversion:

• 20 mg PO q8h ≈ 0.5 mg/hr IV
• 30 mg PO q8h ≈ 1.2 mg/hr IV
• 40 mg PO q8h ≈ 2.2 mg/hr IV

Infusion rate examples (0.1 mg/mL premix):

Special Populations (general principles):

• Renal impairment: Higher exposure; start at lower end, titrate slowly, monitor BP and renal function
• Hepatic impairment: Decreased clearance; use lower starting dose, slower titration
• Elderly: "Start low, go slow"

Oral Dosing (for completeness):

• IR capsules – hypertension: 20 mg PO q8h; titrate every 3 days. Usual total daily dose 60–120 mg (e.g., 20–40 mg q8h)
• SR – hypertension: 30 mg PO BID; titrate to 30–60 mg BID

Absolute Contraindications:

• Advanced aortic stenosis – Afterload reduction can critically impair coronary perfusion and precipitate collapse
• Known hypersensitivity to nicardipine or formulation components

Precautions:

• Coronary artery disease / angina: Reflex tachycardia and reduced diastolic pressure can worsen angina
• Heart failure / reduced EF: Generally tolerated but may worsen HF in severe LV dysfunction or when combined with beta-blockers; titrate cautiously
• Hepatic impairment: Reduced metabolism → elevated levels; lower doses and slower titration required
• Renal impairment: Increased exposure; cautious titration and close monitoring
• Pregnancy: Used in some protocols for severe preeclampsia/eclampsia, but data remain limited; risk–benefit to be determined by obstetrics team
• Peripheral line use: Risk of phlebitis, thrombosis, and extravasation; use large forearm vein or central line when possible, and rotate peripheral sites regularly

Common:

• Headache
• Flushing
• Dizziness
• Hypotension
• Tachycardia / palpitations
• Nausea / vomiting
• Peripheral edema (more with chronic oral therapy)
• Infusion site reactions: pain, erythema, phlebitis

Serious / Less Common:

• Severe hypotension → syncope, organ ischemia
• Worsening angina or myocardial infarction in CAD
• Heart failure exacerbation in severe LV dysfunction
• Arrhythmias or AV block (rare)
• Thrombophlebitis / venous thrombosis at infusion site
• Rare hypersensitivity reactions; rare liver enzyme elevation

Nicardipine is a CYP3A4 substrate and moderate inhibitor, and also interacts with CYP2D6, 2C8, 2C19 and P-gp.

Immunosuppressants:

• Cyclosporine: Nicardipine increases cyclosporine levels; monitor levels closely and reduce cyclosporine dose as needed
• Tacrolimus: Similar considerations; monitor troughs and adjust therapy

CYP3A4 / P-gp Substrates and Modifiers:

• Nicardipine may increase concentrations of CYP3A4 substrates (e.g., some statins and other narrow-therapeutic-index drugs)
• Strong CYP3A4 inducers (e.g., rifampin, carbamazepine) may reduce nicardipine levels and blunt BP effect

Cimetidine:

• Cimetidine can increase nicardipine plasma concentrations; monitor for hypotension and consider dose reduction

Beta-Blockers:

• Combination is common but in patients with HFrEF or severe LV dysfunction, combined effects on contractility and afterload reduction may worsen HF; approach titration cautiously

Other Antihypertensives / Vasodilators:

• Additive BP lowering with nitrates, other CCBs, ACEi/ARB, alpha-blockers, etc.; monitor BP and adjust doses accordingly

Clinical Monitoring:

• Blood pressure: Every 5–15 minutes during initiation and titration; then at regular frequent intervals (often every 15–30 minutes). In high-risk patients, use invasive arterial monitoring when appropriate
• Heart rate and rhythm: Monitor for tachycardia, bradycardia, arrhythmias
• Symptoms: Assess for hypotension, chest pain, dyspnea, neurologic status changes
• Infusion site: Monitor for erythema, pain, palpable cord, swelling (phlebitis or extravasation)

Laboratory / Additional Monitoring:

• Renal function: SCr, BUN, urine output (important in hypertensive emergencies and stroke)
• Liver function tests: With prolonged therapy
• Drug levels where relevant: Cyclosporine, tacrolimus when co-administered
• In neuro patients: Coordinate with neurology/neurosurgery on BP goals vs cerebral perfusion pressure

• 1. Alley, W. D., & Schick, M. A. (2023). Hypertensive emergency. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470371/
• 2. Chiesi USA, Inc. (2018). Cardene I.V. (nicardipine hydrochloride) premixed injection [Prescribing information]. U.S. Food and Drug Administration.
• 3. DrugBank Online. (n.d.). Nicardipine (DB00622). In DrugBank.
• 4. Drugs.com. (2025, August 7). Nicardipine: Package insert / prescribing information. https://www.drugs.com/pro/nicardipine.html
• 5. EBM Consult, LLC. (n.d.). Nicardipine (Cardene): Drug monograph. EBM Consult.
• 6. Medscape. (n.d.). Cardene, Cardene IV (nicardipine) – dosing, indications, interactions, adverse effects, and more [Drug monograph]. Medscape Reference.
• 7. Miller, J., McNaughton, C., Joyce, K., Binz, S., & Levy, P. (2020). Hypertension management in emergency departments. American Journal of Hypertension, 33(10), 927–934. https://doi.org/10.1093/ajh/hpaa068