Injectable nicardipine is increasingly being used to manage neurovascular conditions. To better understand its place in
therapy, we conducted an evidenced-based literature review. Two-hundred twenty-three article abstracts were identified; after independent review by two individuals and a supplemental manual search, 29 were deemed relevant and were included in this review.
Nicardipine has been studied or recommended for management of
hypertension in many neurovascular settings (
ischemic stroke,
intracerebral hemorrhage,
craniotomy, and spinal surgery), for vasospasm in
aneurysmal subarachnoid hemorrhage, and in acute
traumatic brain injury. In the management of
hypertension in
acute stroke,
nicardipine is one of several recommended options available; expert opinion forms the basis of these recommendations in clinical guidelines, with limited randomized controlled trial evidence to support its use. Among the various
antihypertensive agents,
nicardipine has the highest
drug acquisition cost. In two meta-analyses, intravenous
nicardipine had no impact on patient outcomes (death, disability) in patients with acute
traumatic brain injury (relative risk [RR] 0.25, 95% confidence interval [CI] 0.05-1.27) or in patients with aneursymal
subarachnoid hemorrhage (RR 0.97, 95% CI 0.78-1.20). Intraarterial
nicardipine reduced angiographic diameter (p value not reported) and peak systolic velocities on transcranial Doppler images (p<0.001) in published case series. Given
nicardipine's high cost relative to that of other agents and the limited evidence to support its use in patients with neurovascular conditions, this
drug should be considered only in patients who have failed or have
contraindications to alternative agents in the management of
hypertension. Although intraarterial
nicardipine appears to be promising in
aneurysmal subarachnoid hemorrhage, well-designed studies are needed in this setting before its use can be routinely recommended.