Common antihypertensive drugs used in children

(Prepared by Dr Abhishek Kulkarni and Dr Veena V Nair)

Name

Dose

Contra-indication

Side effects

Amlodipine

Start with 0.05- 0.2 mg/kg/24 hrs once or twice daily. Increased to a max. dose of 0.6  mg/kg/24 hr upto 5 mg/24hr

 

Dose related- Edema, dizziness, flushing, fatigue, and palpitations.

Others- headache, nausea, abdominal pain, and somnolence

Atenolol

0.8–1.5 mg/kg/24 hr PO

Max. dose: 2 mg/kg/24 hr

Pulmonary edema, cardiogenic shock

Caution - diabetes and asthma

Bradycardia, hypotension, second- or third-degree AV block, dizziness, fatigue, lethargy, and headache.

Captopril

Neonate: 0.05–0.1 mg/kg/dose upto 0.5mg/kg/dose PO Q8–24 hr.

Infant <6mo: Initially 0.01–0.5   mg/kg/dose PO BID–TID; titrate upward if needed; max. dose: 6 mg/kg/24 hr Q 8-12 hr

Child: Initially 0.3–0.5 mg/kg/dose PO BID–TID; titrate upward if needed; max. dose: 6 mg/kg/24 hr up to 450 mg/24 hr

Caution -collagen vascular disease and concomitant potassium sparing diuretics. Avoid use with dialysis with high-flux membranes for fear of  anaphylactoid reactions .

 

Rash, proteinuria, neutropenia, cough, angioedema, hyperkalemia, hypotension, or diminution of taste perception

Chlorothiazide

<6 mo: 20–40 mg/kg/24 hr χ Q12 hr PO/IV; alternatively, lower IV doses of 2–8 mg/kg/24 hr χ Q12 hr may be used.

 

≥6 mo: 20 mg/kg/24 hr χ Q12 hr PO/IV; alternatively, lower IV doses of 4 mg/kg/24 hr χ Q12–24 hr may be used.

Max PO dose ≤2 yr: 375 mg/24 hr

                      2–12 yr: 1 g/24 hr

Caution- liver and severe renal disease.

Increase serum calcium, bilirubin, glucose, and uric acid. May cause alkalosis, pancreatitis, dizziness, hypokalemia, and hypomagnesemia

Clonidine

5–10 mcg/kg/24 hr PO  2-4 divided doses.  max. dose:  0.9 mg/24 hr.

Do not abruptly discontinue; signs of sympathetic overactivity may occur; taper gradually over >1 wk

Dry mouth, dizziness, drowsiness, fatigue, constipation, anorexia, arrhythmias, and local skin reactions with patch.

Diazoxide

Newborn and infant: 8–15 mg/kg/24 hr χ Q8–12 hr PO

Child and adult: 3–8 mg/kg/24 hr χ Q8–12 hr PO

Caution -renal impairment

Sodium and fluid retention in infants, CHF, hirsutism, GI disturbances, transient loss of taste, tachycardia, ketoacidosis, tachycardia, palpitation

Diltiazem

Child: 1.5–2 mg/kg/24 hr PO χ TID–QID; max. dose: 3.5 mg/kg/24 hr, alternative max. dose of 6 mg/kg/24 hr up to 360 mg/24 hr has been recommended

Adolescent- Immediate release: 30–120 mg/dose PO TID–QID; usual range 180–360mg/24hr. Extended release:120–300 mg/24 hr PO χ OD-BID

CI- acute MI with pulmonary congestion, second- or third-degree heart block, and sick sinus

Caution- CHF or renal and hepatic impairment

Dizziness, headache, edema, nausea, vomiting, heart block, and arrhythmias

Enalapril maleate

PO: 0.1 mg/kg/24 hr up to 5 mg/24 hr χ QD–BID; increase PRN over 2 wk. Max. dose: 0.6 mg/kg/24 hr up to 40 mg/24 hr. IV: 0.005–0.01 mg/kg/dose Q8–24 hr

CI- b/l renal artery stenosis

Avoid use with dialysis with high-flux membranes for fear of anaphylactoid reactions.

Nausea, diarrhea, headache,dizziness, hyperkalemia, hypoglycemia, hypotension ,dry cough and hypersensitivity

Frusemide

IV- 1mg/kg/dose Q 4-6 hr

PO- 1-2 mg/kg/dose  upto 6 mg/kg/24 hr, Q6-12 hr

 

Hypokalemia , alkalosis

Hydralazine hydrochloride

Hypertensive crisis  - 0.1–0.2 mg/kg/dose IM or IV Q4–6 hr PRN; max. dose: 20 mg/dose.

Chronic hypertension - Start at 0.75–1 mg/kg/24 hr PO χ Q6–12 hr (max. dose: 25 mg/dose). If necessary, increase dose over 3–4 wk up to a max. dose of 5 mg/kg/24 hr for infants and 7.5 mg/kg/24 hr for children

Caution - Severe renal and cardiac disease

Reflex tachycardia, palpitations, dizziness, headaches, GI discomfort and lupus like syndrome.

Hydrochloro thiazide

Start at 0.5–1 mg/kg/24 hr QD PO; dose may be increased to a max. dose of 3 mg/kg/24 hr up to 50 mg/24 hr

Caution- renal impairement

Fluid and electrolyte imbalances and hyperuricemia

Labetalol

PO: Initial: 4 mg/kg/24 hr χ BID. May increase up to 40 mg/kg/24 hr

IV: (Hypertensive emergency)- Intermittent dose: 0.2–1 mg/kg/dose Q10 min PRN; max. dose: 20 mg/dose. Infusion : 0.4–1 mg/kg/hr, to a max. dose of 3 mg/kg/hr; may initiate with a 0.2–1 mg/kg bolus; max. bolus: 20 mg

CI- asthma, pulmonary edema, cardiogenic shock, and heart block.

 

Lisinopril

6–16 yr: Start with 0.07 mg/kg/dose PO QD; max. initial dose: 5 mg/dose. If needed, titrate dose upward to doses up to 0.61 mg/kg/24 hr or 40 mg/24 hr

CI- hypersensitivity and history of angioedema with other ACE inhibitors

Caution- aortic or bilateral renal artery  and with NSAIDs

Avoid- dialysis with high-flux membranes

Same as enalapril

Losartan

<6 yrs and creatinine clearance <30ml/mt/1,73sqm - not recommended

≥6 yr: Start with 0.75 mg/kg/dose PO QD up to 50 mg/24 hr. Adjust dose to desired blood pressure response. Max. dose: 1.4 mg/kg/24 hr or 100 mg/24 hr.

Caution- angioedema ,  hepatic (use lower starting dose) or renal (contains potassium) impairment, hyperkalemia, renal artery stenosis and severe CHF.

 

Methyl Dopa

10 mg/kg/24 hr χ Q6–12 hr PO; increase PRN Q2 days. Max dose 65 mg/kg/day

Hypertensive crisis: 2–4 mg/kg/dose IV to a max. dose of 5–10 mg/kg/dose IV Q6–8 hr.

CI- pheochromocytoma and active liver disease

Caution- patient is receiving haloperidol, propranolol, lithium, sympathomimetics

Hemolytic anemia (Coomb’s positive), fever, leukopenia, sedation, memory impairment, hepatitis, GI disturbances, orthostatic hypotension, black tongue, and gynecomastia

Metoprolol

Child ≥ 1 yr and adolescent: Start at 1–2 mg/kg/24 hr PO χ BID; max. dose: 6 mg/kg/24 hr up to 200 mg/24 hr.

CI- sinus bradycardia, heart block > 1st degree, sick sinus syndrome, cardiogenic shock and uncompensated CHF.

Caution- hepatic dysfunction, peripheral vascular disease, history of severe anaphylactic hypersensitivity drug reactions, pheochromocytoma

 

Minoxidil

Child < 12 yr: Start with 0.1–0.2 mg/kg/24 hr PO QD; max. dose: 5 mg/24 hr. Dose may be increased in increments of 0.1–0.2 mg/kg/24 hr at 3-day intervals. Usual effective range: 0.25–1 mg/kg/24 hr PO χ QD-BID; max. dose: 50 mg/24 hr.

>12 yrs- Oral: Start with 5 mg QD. Dose may be gradually increased at 3-day intervals. Usual effective range: 10–40 mg/24 hr χ QD-BID; max. dose: 100 mg/24 hr

CI- acute MI, dissecting aortic aneurysm, and pheochromocytoma

Caution- Renal failure, dialysis, concurrent use of other antihypertensives.

Drowsiness, dizziness, CHF, pulmonary edema, pericardial effusion, pericarditis, thrombocytopenia, leukopenia, Stevens-Johnson syndrome and hypertrichosis

Nicardipine

Continuous IV infusion: 0.5–5 mcg/kg/min

CI- advanced aortic stenosis

Caution-liver and renal dysfunction

Headache, dizziness, asthenia, peripheral edema, and GI symptoms

Nifedepine

  PO:Sustained release: Start with 0.25–0.5 mg/kg/24 hr χ Q12–24 hr. May increase to max. dose: 3 mg/kg/24 hr up to 120 mg/24 hr

Caution-  acute CNS injury, CHF and aortic stenosis

Severe hypotension, peripheral edema, flushing, tachycardia, headaches, dizziness, nausea, palpitations, and syncope

Nitroglycerine

Continuous IV infusion: Begin with 0.25–0.5 mcg/kg/min; may increase by 0.5–1 mcg/kg/min Q3–5 min PRN. Usual dose: 1–5 mcg/kg/min. Max. dose: 20 mcg/kg/min.

CI- glaucoma and severe anemia

Caution- severe renal impairment, increased ICP and hepatic failure

Headache, flushing, GI upset, blurred vision, and methemoglobinemia

Nitroprusside

IV continuous infusion: Start at 0.5 mcg/kg/min, titrate to effect; can increase as need to 5 mcg/kg/min

CI- decreased cerebral perfusion and increased ICP

Hypotension,metabolic acidosis, methhemoglobinemia, psychosis, seizures, rarely hypothyroidism (thiocyanate)

Prazocin

0.1mg/kg/24hrs χ  q 6hrly max:0.4 mg/kg/24 hrs

 

Syncope , palpitation, dizziness, fluid retention. first dose hypotension phenomenon

Propranolol

PO: Initial: 0.5–1 mg/kg/24 hr χ Q6–12 hr. May increase dose Q3–5 days PRN; max. dose: 8 mg/kg/24 hr

CI- asthma, Raynaud's syndrome, heart failure, and heart block

Hypoglycemia, hypotension, nausea, vomiting, depression, weakness,   impotence,

bronchospasm, heart block and cutaneous reactions, including Stevens-Johnson syndrome, TEN, exfoliative dermatitis, erythema multiforme, and utricaria

Phenoxy benzamine

PO-0.2-2 mg/kg/24hr χ Q8-12 hr, max single dose 40 mg Q 8-12 hr

 

Nasal congestion, dizziness, tachycardia, arrhythmia

Phentolamine

IV- 0.05- 0.1 mg/kg/dose, max 20 mg Q1-2 hr

 

Tachycardia, dizziness, nasal congestion, chest pain