Eric C. Lawson, MD; Karen Berger, PharmD
Authors: @sa_saldana1; @pharmer_mikerx
Full Twitter Thread: https://twitter.com/neurocritical/status/1485992755977457665?s=21
January’s Twitter Journal Club featured a discussion on the article, Comparison of Clevidipine and Nicardipine for Acute Blood Pressure Reduction in Hemorrhagic Stroke by Sara Saldana et al. This study was a single-center retrospective observational cohort study with a primary outcome of time to goal systolic blood pressure. Secondary outcomes included need for additional antihypertensives, percentage of time at goal SBP, all-cause mortality, 30-day readmission, rebleeding, total volume of antihypertensive infusion, hematoma expansion, intensive care unit length of stay, hospital length of stay, and cost of infusion. The authors concluded “In patients with hemorrhagic stroke, nicardipine appeared to have similar efficacy as clevidipine in SBP reduction, with a more likely reduction of rebound hypertension and drug cost.”
A lively discussion was had on the #NCSTJC Twitterverse, let's review some of the conclusions and key points.
While some reported an initial preference for IV hydralazine or IV labetalol while awaiting the nicardipine drip, others were concerned about the rebound effects of IV push medications and the variability they may introduce in blood pressure management. Interestingly, the international crowd weighed in on the differences in medication availability around the world.
Though the answers to question 2 had varied replies, in the participants’ opinion, the shorter duration of action of clevidipine is a good thing as it allows for easy titration on and off. The comments on this question raised some important points of international accessibility of clevidipine and nicardipine. @betatt81 stated “That’s the reality in Brazil too. We only have Nitroprusside IV to use in drip. My dream was to have experience using this alternatives [sic] that I only see in papers.”
The general consensus amongst participants was that the raw numbers of time to goal SBP were not relevant to the overall findings or more specifically, hematoma expansion. @gdomeni captured many opinions with his comment “not relevant really to hematoma volume difference. I don’t believe that less hematoma expansion have narrow relation with this time. There are other factors.”
Author, Sara Saldana, (@sa_saldana1) responded that “No, this doesn’t affect my interpretation based on the analyses completed. In the multiple linear regression, time to goal SBP wasn’t affected by baseline SBP. In the PS matched cohort, there was no significant difference in time to goal SBP.”
The results of the Question 5 poll clearly demonstrated this audience’s opinion that hemorrhagic expansion was the most meaningful outcome to assess in blood pressure lowering studies. Some comments indicated an opinion that other metrics might be more meaningful, for instance @KeatonSmetana stated “Most meaningful in my mind are interventions that improve QOL/decrease mortality,” to which @Karenccrx replied “Agree. I’m not sure we can keep extrapolating that small reductions in hem expansion (ie, a few mL) are always assoc [sic] with mortality/mRS benefits.”
@EM_NCC stated “I’ve seen more hypotension with nicardipine possibly from rapid titration than rebound HTN with either agents. Anyone else?” Numerous replies indicated the groups opinion that nicardipine is often titrated too quickly resulting in hypotension and frequent dosage changes. Regarding the rebound hypertension in the nicardipine group @trob_pharmd stated “I think this is directly related to the difference in half-life between clevidipine and nicardipine.”
The January edition of the #NCSTJC generated great discussion regarding the use of nicardipine and clevidipine as blood pressure lowering agents in acute intracerebral hemorrhage. From the discussion it is clear, there is not a current consensus on a superior agent amongst the participants. For now, many will continue to face institutional or international constraints on medication choice depending on which infusion is available locally, but this important work provides preliminary evidence that a prospective randomized trial comparing clevidipine against alternative agents may be warranted.
Read the full article from the January Twitter Journal Club here: https://link.springer.com/article/10.1007/s12028-021-01407-w