In this episode, I’ll discuss clevidipine vs nicardipine and the time to reach goal BP in a hypertensive crisis.
The extra expense of clevidipine is often justified by the idea that it has a faster onset of action than other similar medications such as nicardipine. While the faster onset of action for clevidipine has been found in stroke and cardiothoracic surgery patients, it has not been shown to result in a clinically meaningful benefit to patients. When clevidipine is available, clinicians may wish to use it to treat hypertensive crises, where perhaps a faster onset of action could lead to a patient-centered benefit.
A group of authors recently published in AJHP a multicenter, retrospective cohort study including patients who received either clevidipine or nicardipine for treatment of hypertensive crisis.
The study analyzed 182 patients who received either clevidipine or nicardipine for treatment of hypertensive crisis (103 receiving nicardipine and 79 receiving clevidipine).
The primary outcome the investigators looked at was the time from infusion start to attainment of goal BP. For the purposes of this outcome, goal BP was defined as the higher value of the guideline-directed 25% reduction in BP or the physician-ordered goal. Secondary outcomes were the time from infusion start to guideline-directed 25% reduction in BP, drug and total volume intake, the time from order entry to BP goal attainment, the number of BP and heart rate excursions, intensive care unit (ICU) length of stay, and study medication cost.
The clevidipine group took on average 37 minutes to reach goal BP, and the nicardipine group took 35 minutes. This difference was not statistically significant. While drug volume was significantly less in the clevidipine group, the total volume received while in the ICU was not different between groups. The percent of time in the goal BP range was nearly identical between groups, and the cost of clevidipine was about 7 times higher than for nicardipine.
The authors concluded:
Time to goal BP was similar for clevidipine and nicardipine in this population. Any decreases in medication-associated volume with clevidipine were no longer evident when all volume sources were considered. These results show that clevidipine may not provide meaningful benefit in this heterogenous population. The difference in cost does not seem justified given the lack of improvement in clinically relevant outcomes.
Despite the faster onset of action in controlled studies, it does not appear based on this retrospective analysis of real-world conditions that clevidipine offers a speed advantage over nicardipine getting to goal BP in patients with hypertensive crises.
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