Rabies Vaccination in Patients with Severely Elevated Blood Pressure

Key Principles

The Centers for Disease Control and Prevention recommends that a patient with severely elevated blood pressure should receive antirabies vaccine without delay, as hypertension is not a contraindication to rabies post-exposure prophylaxis, and rabies is universally fatal without treatment 1, 2
Rabies post-exposure prophylaxis must be initiated immediately regardless of any concurrent medical conditions, including severe hypertension, as stated by the CDC 1, 3
There are no absolute contraindications to rabies vaccination when exposure has occurred, according to the CDC and MMWR Recommendations and Reports 1, 4

The Advisory Committee on Immunization Practices (ACIP) guidelines state that the rabies vaccine and rabies immunoglobulin (HRIG) can be safely administered to patients with any level of blood pressure elevation 1, 5
For previously unvaccinated patients, administer HRIG at 20 IU/kg body weight on day 0, and give rabies vaccine (HDCV or PCECV) 1.0 mL intramuscularly in the deltoid on days 0, 3, 7, and 14, as recommended by the ACIP 1, 3
For previously vaccinated patients, give only vaccine (no HRIG) on days 0 and 3, according to the ACIP guidelines 1, 2

The European Society of Cardiology recommends that while administering rabies prophylaxis, simultaneously initiate or optimize antihypertensive therapy according to standard hypertension guidelines 6, 7
For severely elevated blood pressure (≥180/120 mmHg), consider immediate blood pressure lowering with appropriate agents (ACE inhibitors, ARBs, CCBs, or diuretics) while proceeding with rabies vaccination, as stated by the European Heart Journal 6, 7

The CDC advises to never delay or withhold rabies post-exposure prophylaxis for any reason, including uncontrolled hypertension 1, 3
Never administer the vaccine in the gluteal area, as this produces inadequate antibody titers, according to the CDC and MMWR Recommendations and Reports 1, 3
Never give HRIG to previously vaccinated persons, as it will suppress the anamnestic response, as recommended by the ACIP 2, 3
Never administer HRIG and vaccine in the same syringe or anatomical site, according to the CDC and MMWR Recommendations and Reports 1, 3