Agents to Avoid in Hypertensive Emergency

High-Risk Agents Requiring Caution or Avoidance

Sodium nitroprusside should be used with extreme caution or avoided entirely due to cyanide toxicity risk, particularly with prolonged infusions or doses ≥4 mcg/kg/min for >30 minutes, as recommended by the American Heart Association 1
Cyanide toxicity risk increases substantially with infusion rates ≥4-10 mcg/kg/min or duration >30 minutes, according to the American Heart Association 1
Thiosulfate coadministration is required for higher doses or prolonged use to prevent cyanide toxicity, as stated by the American Heart Association 1
Sodium nitroprusside is contraindicated in liver/kidney failure, and decreases regional coronary blood flow in patients with coronary abnormalities, increasing myocardial damage after acute MI, as reported by the European Society of Cardiology 2
Sodium nitroprusside should not be used in acute coronary syndromes due to adverse coronary effects, as recommended by the European Society of Cardiology 2
Hydralazine is associated with adverse perinatal outcomes in pregnancy, making it less preferred than labetalol or nicardipine for severe preeclampsia, according to the European Society of Cardiology 3

Labetalol should be avoided in second or third-degree AV block, systolic heart failure, asthma, reactive airways disease, bradycardia, and pheochromocytoma, as recommended by the European Society of Cardiology 2
Labetalol should also be avoided in COPD, as stated by the European Society of Cardiology, although this is also reported by Praxis Medical Insights, the European Society of Cardiology recommendation is preferred 3

Beta-blockers, including labetalol, are relatively contraindicated in cocaine/amphetamine intoxication, as they do not effectively reduce coronary vasoconstriction, according to the European Society of Cardiology 3
Benzodiazepines should be initiated first, followed by phentolamine, nicardipine, or nitroprusside if needed, in cases of cocaine/amphetamine intoxication, as recommended by the European Society of Cardiology 3
Nitroprusside is contraindicated in eclampsia/preeclampsia due to risk of fetal cyanide toxicity, as reported by the European Society of Cardiology 3
Cumulative labetalol dose should not exceed 800 mg/24h to prevent fetal bradycardia in eclampsia/preeclampsia, according to the European Society of Cardiology 3

Oral agents should never be used for true hypertensive emergencies with acute end-organ damage, as recommended by the American Heart Association 1
Rapid BP reduction beyond 25% in the first hour should be avoided, except in cases of aortic dissection, severe preeclampsia, or pheochromocytoma, to prevent organ hypoperfusion, as stated by the American Heart Association and the European Society of Cardiology, although the American Heart Association recommendation is preferred 1
Fenoldopam should be avoided in patients with increased intraocular pressure, glaucoma, or sulfite allergy, as reported by Praxis Medical Insights, however since there is no other source, this will be included 4