It is recommended to administer nicardipine with caution to avoid an excessive fall in blood pressure. In fact, rapid pharmacologic reductions in blood pressure may produce systemic hypotension and reflex tachycardia. If either occurs with nicardipine, it may be necessary to reduce the dose by half or stop the infusion.
Bolus administration or intravenous administration not controlled by the use of an electronic syringe driver or a volumetric pump is not recommended and can increase the risk of severe hypotension, particularly in the elderly, in children, in patients with renal or hepatic failure and during pregnancy.
Cardiac failure: Nicardipine should be used with caution in patients with congestive cardiac failure or pulmonary oedema, particularly when these patients are receiving concomitant beta-blockers, as worsening of cardiac failure may occur.
Ischaemic cardiovascular disease: Nicardipine is contra-indicated in unstable angina and immediately following myocardial infarction (see Contraindications).
Nicardipine should be used with caution in patients with suspected coronary ischaemia. Occasionally, patients have developed an increased frequency, duration, or severity of angina upon starting or increasing nicardipine dosage, or during the course of treatment.
Patients with history of hepatic dysfunction or hepatic failure: Rare cases of abnormal hepatic function possibly associated with the administration of nicardipine have been reported. Potential risk groups are patients with a history of hepatic dysfunction or those with hepatic failure at the initiation of treatment with nicardipine. Nicardipine should be used with particular caution in patients with hepatic failure.
Renal failure: Nicardipine should be used with caution in patients with renal failure (see Pharmacology: Pharmacokinetics under Actions).
Patients with portal hypertension: Intravenous nicardipine at high doses has been reported to worsen portal vein hypertension and portal-systemic collateral blood flow index in cirrhotic patients.
Patients with pre-existing intracranial hypertension: Nicardipine should be used with caution in patients with a risk of increased intracranial pressure. Intracranial pressure should be monitored, to allow calculation of the cerebral perfusion pressure.
Patients with stroke: Nicardipine should be used with caution in patients with acute cerebral infarction. A hypertensive episode which often accompanies a stroke is not an indication for emergency antihypertensive therapy. The use of antihypertensive medicinal products is not recommended in ischaemic stroke patients unless acute hypertension precludes the administration of an adequate treatment (e.g. thrombolysis) or there is other organ damage which is life-threatening in the short term.
Use in Pregnancy: Due to the risk of severe maternal hypotension and potentially fatal foetal hypoxia, the decrease in blood pressure should be progressive and always closely monitored. Due to the possible risk of pulmonary oedema or excessive decrease in blood pressure, caution should be taken if magnesium sulphate is used concomitantly.
As cases of acute pulmonary oedema have been reported during pregnancy, nicardipine should be administered with caution in pregnant women, who should be closely monitored to detect any possible onset of acute pulmonary oedema. If an acute pulmonary oedema occurs, nicardipine treatment should be immediately stopped and an appropriate treatment should be initiated.