Cardene
nicardipine hydrochloride
Pharmacologic class: Calcium channel blocker
Therapeutic class: Antianginal, antihypertensive
Pregnancy risk category C
Action
Inhibits calcium transport into myocardial and vascular smooth muscle cells, causing cardiac output and myocardial contractions to decrease
Availability
Capsules: 20 mg, 30 mg
Capsules (sustained-release): 30 mg, 45 mg, 60 mg
Injection: 2.5 mg/ml in 10-ml ampules
Indications and dosages
➣ Chronic stable angina, given alone or with beta-adrenergic blockers
Adults: Titrate dosage individually, starting with 20 to 40 mg P.O. (immediate-release) t.i.d. Wait at least 3 days before increasing dosage.
➣ Hypertension, given alone or with other antihypertensives
Adults: Titrate dosage individually, starting with 20 mg P.O. (immediate release) t.i.d. Wait at least 3 days before increasing dosage. Dosage range is 20 to 40 mg P.O. t.i.d. Patient may be switched to sustained-release capsules at nearest equivalent daily dosage of immediate-release capsules, starting with 30 mg P.O. b.i.d. Effective range is 30 to 60 mg/day.
➣ Short-term treatment of hypertension when oral therapy isn't feasible or desirable
Adults: Continuous I.V. infusion of 0.5 mg/hour (equal to 20 mg P.O. q 8 hours), or 1.2 mg/hour (equal to 30 mg P.O. q 8 hours), or 2.2 mg/hour (equal to 40 mg P.O. q 8 hours)
Off-label uses
• Raynaud's disease
• Heart failure
• Migraine
Contraindications
• Hypersensitivity to drug
• Advanced aortic stenosis
Precautions
Use cautiously in:
• hepatic or mild renal impairment
• hypotension, heart failure, significant left ventricular dysfunction
• pheochromocytoma
• pregnant or breastfeeding patients (safety not established)
• children younger than age 18 (safety not established).
Administration
• Give immediate-release capsules without regard to meals; if GI upset occurs, give with meals. Don't give with grapefruit or grapefruit juice.
• Don't open, crush, break, or let patient chew sustained-release capsules. Give with meals, but not with high-fat meals, grapefruit, or grapefruit juice.
• For I.V. use, dilute each 25-mg ampule with 240 ml of compatible I.V. fluid (such as dextrose 5% in water, normal saline solution, dextrose 5% with normal saline solution, or half-normal saline solution) to a concentration of 0.1 mg/ml.
Don't dilute with sodium bicarbonate 5% or lactated Ringer's injection (incompatible).
• Don't mix with furosemide, heparin, or thiopental.
Give by slow I.V. infusion. Titrate dosage to blood pressure response.
Adverse reactions
CNS: dizziness, headache, asthenia, drowsiness, paresthesia
CV: hypotension, peripheral edema, chest pain, increased angina, palpitations, tachycardia
GI: nausea, dyspepsia, dry mouth
Musculoskeletal: myalgia
Skin: flushing
Interactions
Drug-drug. Cimetidine: increased nifedipine blood level
Cyclosporine: increased cyclosporine blood level
Fentanyl anesthesia: increased hypotension
Drug-food. Grapefruit, grapefruit juice: increased drug blood level and effects
High-fat meal (sustained-release form): decreased drug blood level
Drug-herbs. Ephedra (ma huang), yohimbine: antagonism of drug's anti-hypertensive effect
St. John's wort: decreased nifedipine blood level
Drug-behaviors. Alcohol use: additive hypotension, increased drowsiness or dizziness
Patient monitoring
• Assess vital signs and cardiovascular status.
• Monitor fluid intake and output. Assess for signs and symptoms of heart failure.
Patient teaching
• Tell patient he may take immediate-release capsules without regard to meals. If GI upset occurs, advise him to take them with food, but not with grapefruit or grapefruit juice.
• Tell patient not to open, crush, break, or chew sustained-release capsules. Instruct him to take them with meals, but not with high-fat meals, grapefruit, or grapefruit juice.
• Tell patient to monitor blood pressure and report abnormal findings.
Advise patient to immediately report chest pain or blood pressure drop.
• Instruct patient to consult prescriber before drinking alcohol or taking herbs or over-the-counter drugs (especially cold remedies).
• As appropriate, review all other significant adverse reactions and interactions, especially those related to the drugs, foods, herbs, and behaviors mentioned above.
niCARdipine
(nye-kar-di-peen) nicardipine,Cardene
(trade name),Cardene SR
(trade name),Cardene IV
(trade name)Classification
Therapeutic: antianginalsPharmacologic: calcium channel blockers
Indications
- Hypertension,
- Angina pectoris,
- Vasospastic (Prinzmetal’s) angina.
Action
Therapeutic effects
Pharmacokinetics
Time/action profile (cardiovascular effects)
| ROUTE | ONSET | PEAK | DURATION |
|---|---|---|---|
| PO | 20 min | 0.5–2 hr | 8 hr |
| PO-ER | unknown | unknown | 12 hr |
| IV | within min | 45 min | 50 hr† |
Contraindications/Precautions
Adverse Reactions/Side Effects
Central nervous system
- abnormal dreams
- anxiety
- confusion
- dizziness
- drowsiness
- headache
- jitteriness
- nervousness
- psychiatric disturbances
- weakness
Ear, Eye, Nose, Throat
- blurred vision
- disturbed equilibrium
- epistaxis
- tinnitus
Respiratory
- cough
- dyspnea
- shortness of breath
Cardiovascular
- arrhythmias (life-threatening)
- HF (life-threatening)
- peripheral edema (most frequent)
- bradycardia
- chest pain
- hypotension
- palpitations
- syncope
- tachycardia
Gastrointestinal
- ↑ liver function tests
- anorexia
- constipation
- diarrhea
- dry mouth
- dysgeusia
- dyspepsia
- nausea
- vomiting
Genitourinary
- dysuria
- nocturia
- polyuria
- sexual dysfunction
- urinary frequency
Dermatologic
- dermatitis
- erythema multiforme
- flushing
- ↑ sweating
- photosensitivity
- pruritus/urticaria
- rash
Endocrinologic
- gynecomastia
- hyperglycemia
Hematologic
- anemia
- leukopenia
- thrombocytopenia
Metabolic
- weight gain
Musculoskeletal
- joint stiffness
- muscle cramps
Neurologic
- paresthesia
- tremor
Miscellaneous
- stevens-johnson syndrome (life-threatening)
- gingival hyperplasia
Interactions
Drug-Drug interaction
Additive hypotension may occur when used concurrently with fentanyl, other antihypertensives, nitrates, acute ingestion of alcohol, or quinidine.Antihypertensive effects may be ↓ by concurrent use of NSAIDs.Concurrent use with beta blockers, digoxin, disopyramide, or phenytoin may result in bradycardia, conduction defects, or HF.Cimetidine and propranolol may ↓ metabolism and ↑ risk of toxicity.May ↓ the metabolism of and ↑ risk of toxicity from cyclosporine, prazosin, quinidine, or carbamazepine.Grapefruit and Grapefruit juice ↑ serum levels and effect.Route/Dosage
Availability (generic available)
Nursing implications
Nursing assessment
- Monitor BP and pulse prior to therapy, during dose titration, and periodically throughout therapy. Monitor ECG periodically during prolonged therapy.
- Monitor intake and output ratios and daily weight. Assess for signs of HF (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention).
- Assess for rash periodically during therapy. May cause Stevens-Johnson syndrome. Discontinue therapy if severe or if accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis, and/or eosinophilia.
- Angina: Assess location, duration, intensity, and precipitating factors of patient’s anginal pain.
- Lab Test Considerations: Total serum calcium concentrations are not affected by calcium channel blockers.
- Monitor serum potassium periodically. Hypokalemia ↑ risk of arrhythmias; should be corrected.
- Monitor renal and hepatic functions periodically during long-term therapy. Several days of therapy may cause ↑ hepatic enzymes, which return to normal upon discontinuation of therapy.
Potential Nursing Diagnoses
Decreased cardiac output (Indications)Acute pain (Indications)
Implementation
- Do not confuse nicardipine with nifedipine or nimodipine.
- To transfer from IV nicardipine infusion to oral therapy with other antihypertensive, start oral therapy simultaneously with discontinuation of nicardipine infusion. If transferring to oral nicardipine therapy, administer first dose of a 3-times-a-day regimen 1 hr prior to discontinuation of infusion.
- Dose adjustments of nicardipine should be made no more frequently than every 3 days.
- Oral: May be administered without regard to meals. May be administered with meals if GI irritation becomes a problem.
- Do not open, break, crush, or chew sustained-release capsules.
Intravenous Administration
- pH: 3.5–4.7.
- Continuous Infusion: Diluent: Dilute each 25-mg ampule with 240 mL of D5W, D5/0.45% NaCl, D5/0.9% NaCl, 0.45% NaCl, or 0.9% NaCl. Infusion is stable for 24 hr at room temperature.Concentration: 0.1 mg/mL.
- Rate: Titrate rate according to BP response. Administer through large peripheral veins or central veins to reduce risk of venous thrombosis, phlebitis, local irritation, swelling, extravasation, and vascular impairment. Change infusion site every 12 hours to minimize risk of peripheral venous irritation.
- Y-Site Compatibility: alemtuzumab, amikacin, aminophylline, anidulafungin, argatroban, aztreonam, bivalirudin, bleomycin, butorphanol, calcium gluconate, carboplatin, carmustine, caspofungin, cefazolin, chloramphenicol, cisplatin, clindamycin, cytarabine, daptomycin, dexmedetomidine, diltiazem, dobutamine, docetaxel, dopamine, doxacurium, doxorubicin hydrochloride, enalaprilat, epinephrine, epirubicin, eptifibatide, erythromycin, esmolol, famotidine, fenoldopam, fentanyl, gentamicin, hetastarch, hydrocortisone sodium succinate, hydromorphone, idarubicin, irinotecan, labetalol, lidocaine, linezolid, lorazepam, magnesium sulfate, mechlorethamine, methylprednisolone sodium succinate, metronidazole, midazolam, milrinone, mitoxantrone, morphine, mycophenolate, nafcillin, nesiritide, nitroglycerin, nitroprusside, norepinephrine, octreotide, oxaliplatin, oxytocin, palonosetron, pamidronate, penicillin G potassium, potassium chloride, potassium phosphates, quinupristin/dalfopristin, ranitidine, rocuronium, tacrolimus, tirofiban, tobramycin, trimethoprim/sulfamethoxazole, vancomycin, vasopressin, vecuronium, vincristine, voriconazole, zoledronic acid
- Y-Site Incompatibility: aminocaproic acid, amphotericin B lipid complex, amphotericin B liposome, ampicillin, ampicillin/sulbactam, cefepime, cefoperazone, ertapenem, fluorouracil, furosemide, methotrexate, micafungin, pantoprazole, pemetrexed, potassium acetate, thiopental, thiotepa, tigecycline
Patient/Family Teaching
- Advise patient to take medication exactly as directed, even if feeling well. Take missed doses as soon as possible unless almost time for next dose; do not double doses. May need to be discontinued gradually.
- Instruct patient on technique for monitoring pulse. Instruct patient to contact health care professional if heart rate is <50 bpm.
- Advise patient to avoid grapefruit or grapefruit juice during therapy.
- Caution patient to change positions slowly to minimize orthostatic hypotension.
- May cause drowsiness or dizziness. Advise patient to avoid driving or other activities requiring alertness until response to the medication is known.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to avoid concurrent use of alcohol or OTC medications and herbal products, especially cold preparations, without consulting health care professional.
- Advise patient to notify health care professional if rash, irregular heartbeat, dyspnea, swelling of hands and feet, pronounced dizziness, nausea, constipation, or hypotension occurs or if headache is severe or persistent.
- Caution patient to wear protective clothing and to use sunscreen to prevent photosensitivity reactions.
- Angina: Instruct patient on concurrent nitrate or beta-blocker therapy to continue taking both medications as directed and to use SL nitroglycerin as needed for anginal attacks.
- Advise patient to contact health care professional if chest pain does not improve, worsens after therapy, or occurs with diaphoresis; if shortness of breath; or if persistent headache occurs.
- Caution patient to discuss exercise restrictions with health care professional prior to exertion.
- Hypertension: Encourage patient to comply with other interventions for hypertension (weight reduction, low-sodium diet, smoking cessation, moderation of alcohol consumption, regular exercise, and stress management). Medication controls but does not cure hypertension.
- Instruct patient and family in proper technique for monitoring BP. Advise patient to take BP weekly and to report significant changes to health care professional.
Evaluation/Desired Outcomes
- Decrease in BP.
- Decrease in frequency and severity of anginal attacks.
- Decrease in need for nitrate therapy.
- Increase in activity tolerance and sense of well-being.