NiCARdipine Hydrochloride and Strong Iodine Solution

• Generic Name: nicardipine
• Dosage Forms: n.a.
• Other Brand Names: Cardene IV, Cardene SR, Cardene

Oral management of hypertension (alone or in combination with other classes of antihypertensive agents).

Therapy with extended-release capsules generally is preferred because of less frequent dosing, potentially smoother BP control, and concerns raised by experience with short-acting (conventional, immediate-release) nifedipine.

Calcium-channel blockers are recommended as one of several preferred agents for the initial management of hypertension according to current evidence-based hypertension guidelines; other preferred options include ACE inhibitors, angiotensin II receptor antagonists, and thiazide diuretics. While there may be individual differences with respect to recommendations for initial drug selection and use in specific patient populations, current evidence indicates that these antihypertensive drug classes all generally produce comparable effects on overall mortality and cardiovascular, cerebrovascular, and renal outcomes.

Individualize choice of therapy; consider patient characteristics (e.g., age, ethnicity/race, comorbidities, cardiovascular risk) as well as drug-related factors (e.g., ease of administration, availability, adverse effects, cost).

A 2017 ACC/AHA multidisciplinary hypertension guideline classifies BP in adults into 4 categories: normal, elevated, stage 1 hypertension, and stage 2 hypertension.

Source: Whelton PK, Carey RM, Aronow WS et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:e13-115.

Individuals with SBP and DBP in 2 different categories (e.g., elevated SBP and normal DBP) should be designated as being in the higher BP category (i.e., elevated BP).

The goal of hypertension management and prevention is to achieve and maintain optimal control of BP. However, the BP thresholds used to define hypertension, the optimum BP threshold at which to initiate antihypertensive drug therapy, and the ideal target BP values remain controversial.

The 2017 ACC/AHA hypertension guideline generally recommends a target BP goal (i.e., BP to achieve with drug therapy and/or nonpharmacologic intervention) of <130/80 mm Hg in all adults regardless of comorbidities or level of atherosclerotic cardiovascular disease (ASCVD) risk. In addition, an SBP goal of <130 mm Hg is recommended for noninstitutionalized ambulatory patients ≥65 years of age with an average SBP of ≥130 mm Hg. These BP goals are based upon clinical studies demonstrating continuing reduction of cardiovascular risk at progressively lower levels of SBP.

Other hypertension guidelines generally based target BP goals on age and comorbidities. Guidelines such as those issued by the JNC 8 expert panel generally have targeted a BP goal of <140/90 mm Hg regardless of cardiovascular risk and have used higher BP thresholds and target BPs in elderly patients compared with those recommended by the 2017 ACC/AHA hypertension guideline.

Some clinicians continue to support previous target BPs recommended by JNC 8 due to concerns about the lack of generalizability of data from some clinical trials (e.g., SPRINT study) used to support the 2017 ACC/AHA hypertension guideline and potential harms (e.g., adverse drug effects, costs of therapy) versus benefits of BP lowering in patients at lower risk of cardiovascular disease.

Consider potential benefits of hypertension management and drug cost, adverse effects, and risks associated with the use of multiple antihypertensive drugs when deciding a patient's BP treatment goal.

For decisions regarding when to initiate drug therapy (BP threshold), the 2017 ACC/AHA hypertension guideline incorporates underlying cardiovascular risk factors. ASCVD risk assessment is recommended by ACC/AHA for all adults with hypertension.

ACC/AHA currently recommend initiation of antihypertensive drug therapy in addition to lifestyle/behavioral modifications at an SBP ≥140 mm Hg or DBP ≥90 mm Hg in adults who have no history of cardiovascular disease (i.e., primary prevention) and a low ASCVD risk (10-year risk <10%).

For secondary prevention in adults with known cardiovascular disease or for primary prevention in those at higher risk for ASCVD (10-year risk ≥10%), ACC/AHA recommend initiation of antihypertensive drug therapy at an average SBP ≥130 mm Hg or an average DBP ≥80 mm Hg.

Adults with hypertension and diabetes mellitus, chronic kidney disease (CKD), or age ≥65 years are assumed to be at high risk for cardiovascular disease; ACC/AHA state that such patients should have antihypertensive drug therapy initiated at a BP ≥130/80 mm Hg. Individualize drug therapy in patients with hypertension and underlying cardiovascular or other risk factors.

In stage 1 hypertension, experts state that it is reasonable to initiate drug therapy using the stepped-care approach in which one drug is initiated and titrated and other drugs are added sequentially to achieve the target BP. Initiation of antihypertensive therapy with 2 first-line agents from different pharmacologic classes recommended in adults with stage 2 hypertension and average BP >20/10 mm Hg above BP goal.

Calcium-channel blockers may be beneficial in hypertensive patients with certain coexisting conditions (e.g., ischemic heart disease) and in geriatric patients, including those with isolated systolic hypertension.

Calcium-channel blockers may be particularly useful in black patients with hypertension; such patients generally respond better to monotherapy with calcium-channel blockers or thiazide diuretics than to other antihypertensive drug classes (e.g., ACE inhibitors, angiotensin II receptor antagonists). However, the combination of an ACE inhibitor or an angiotensin II receptor antagonist with a calcium-channel blocker or thiazide diuretic produces similar BP lowering in black patients as in other racial groups.

IV, short-term management of hypertension when oral therapy is not feasible or desirable.

IV management of hypertensive crises (e.g., emergencies) in adults.

IV, rapid reduction of BP in the management of acute severe hypertension and life-threatening symptoms in children and adolescents.

Angina

Management of chronic stable angina pectoris (alone or in combination with other antianginal agents).

• Generic Name: potassium iodide
• Dosage Forms: n.a.
• Other Brand Names: IOSAT, ThyroSafe, ThyroShield, Pima, SSKI

Preoperative management of hyperthyroidism in patients with Graves’ disease undergoing thyroidectomy. American Thyroid Association (ATA), American Association of Clinical Endocrinologists (AACE), and others recommend that patients with Graves’ disease scheduled for surgery be rendered euthyroid using other antithyroid agents (preferably methimazole) and then receive potassium iodide for 7–14 days (usually 10 days) in immediate preoperative period. In exceptional circumstances when euthyroid state cannot be achieved prior to thyroidectomy (e.g., urgent need for surgery, allergy to antithyroid drugs), these experts recommend use of potassium iodide and a β-adrenergic blocking agent (e.g., propranolol) in immediate preoperative period. Preoperative potassium iodide has traditionally been used in such patients to decrease thyroid blood flow, vascularity, and intraoperative blood loss; however, some clinicians question necessity and benefits of this strategy.

Management of severe, life-threatening thyrotoxicosis (thyroid storm, thyrotoxicosis crisis) in conjunction with other antithyroid agents (e.g., methimazole, propylthiouracil), β-adrenergic blocking agents (e.g., propranolol), corticosteroids (hydrocortisone, dexamethasone), treatment of hyperpyrexia, and appropriate fluid, electrolyte, and respiratory support. Initiate other antithyroid agents first to block thyroid hormone synthesis and conversion of tetraiodothyronine (thyroxine, T4) to triiodothyronine (T3); initiate potassium iodide 1 hour after the other agents to block new hormone synthesis and thyroid hormone release.

Blockage of thyroidal uptake of radioactive isotopes of iodine (e.g., I 131) that may be released into the environment (e.g., from a nuclear power plant) to minimize the risk of radiation-induced thyroid neoplasms related to internal exposures to radioiodines (inhaled or ingested). Has no impact on uptake of other radioactive materials and does not provide protection against external irradiation of any kind.

Used as an adjunct to other protective measures (e.g., evacuation, sheltering, assurance of uncontaminated milk and food). Individuals unable to tolerate potassium iodide and individuals for whom repeat doses of the drug are a concern (e.g., neonates ≤1 month of age, pregnant or lactating women) should be given priority with regard to these other protective measures.

For use in radiation emergencies, potassium iodide is commercially available in appropriate dosage forms (see Dosage and Administration) and may also be retained in state or local stockpiles.

Decisions to recommend protective measures (including use of potassium iodide) in an emergency situation related to a US nuclear power plant reside with state and/or local government authorities responsible for radiological emergency planning and response. (See Advice to Patients.)

Used to protect thyroid during diagnostic or therapeutic use of radiopharmaceuticals or drugs that have radioactive components (e.g., iodine I 131 tositumomab; no longer commercially available in US).

Initiated prior to administration of radiolabeled diagnostic or therapeutic agent to saturate thyroid and protect it from uptake of radioiodide; continued until estimated activity of radiolabeled agent has decreased to acceptable levels after completion of the procedure or treatment.

Treatment of cutaneous sporotrichosis (localized to skin; also known as fixed cutaneous sporotrichosis) and lymphocutaneous sporotrichosis (involves skin, subcutaneous tissues, regional lymphatics) caused by Sporothrix schenckii.

Because it is inexpensive and generally effective, potassium iodide (oral solution containing 1 g/mL; also known as saturated solution of potassium iodide [SSKI]) has historically been a standard of care for treatment of cutaneous and lymphocutaneous sporotrichosis and is a drug of first choice for these infections in some resource-limited settings and countries where the disease is endemic. However, safety and efficacy for treatment of these infections not established in controlled clinical trials.

IDSA and others recommend itraconazole as drug of choice for treatment of cutaneous and lymphocutaneous sporotrichosis; terbinafine and potassium iodide (oral solution containing 1 g/mL; also known as saturated solution of potassium iodide [SSKI]) are preferred alternatives. Local hyperthermia (i.e., direct application of heat using pocket warmer, infrared or far-infrared heater, or similar device that warms tissue to 42–43°C) is another alternative for treatment of cutaneous sporotrichosis when antifungals or potassium iodide cannot be used (e.g., pregnant or nursing women).

Not effective and should not be used for treatment of extracutaneous sporotrichosis (pulmonary, osteoarticular, meningeal) or disseminated sporotrichosis; IV amphotericin B and oral itraconazole are drugs of choice for these forms of sporotrichosis.

Potassium iodide (oral solution containing 1 g/mL; also known as saturated solution of potassium iodide [SSKI]) has been used as an expectorant in the symptomatic management of chronic pulmonary diseases where tenacious mucus complicates the condition (e.g., bronchial asthma, bronchitis, pulmonary emphysema). However, efficacy not established and the drug generally has been replaced by more effective and safer expectorants.