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Antihypertensive dosing

Drug dosing reference for commonly used blood pressure medications in pediatric patients, specifically for the treatment of hypertension.

Other indications may have different typical doses/ranges. This page does not include dose adjustments for kidney/hepatic impairment.

  • pill
  • liquid
  • compounded liquid
  • injection (IV)
  • continuous infusion (drip/gtt)
  • intramuscular (IM)
  • transdermal (TD)

Calcium channel blockers (CCBs)

Amlodipine (Norvasc®, Katerzia®, Norliqva®)

[UpToDate] [LPCH Lexicomp]

tip

Long elimination half-life (t½ 35-50 hours); may divide BID for a few days to quickly get to steady state

Enteral

  • Age <6: 0.05-0.1 mg/kg once daily
    • Max 0.6 mg/kg/day or 5 mg/day
  • Age ≥6: 2.5-5 mg daily
    • Max 0.6 mg/kg/day or 10 mg/day
      • >10 mg → ↑ side effects, no proven BP benefit
  • Doses >5 mg/day not studied in pediatric patients but are often used in patients aged ≥6

Isradipine (Dynacirc®)

[UpToDate] [LPCH Lexicomp]

Enteral

  • 0.05-0.15 mg/kg q6-8h PRN (≤5 mg/dose)
    • Start with lower dose, especially for age ≤2 years
    • Max 0.6 mg/kg/day or 10 mg/day
      • >10 mg → ↑ side effects, no proven BP benefit
  • Time to effect 1-1.5 hours, with peak effect in 2-3 hours
    • Note: if patient is already on max dose of one calcium channel blocker (e.g., amlodipine), consider using another class for a PRN agent

Clevidipine (Cleviprex®)

[UpToDate] [LPCH Lexicomp]

warning

Oil-in-water emulsion contains soy, egg yolk phospholipids, glycerin and delivers significant lipid load (2 kcal/mL)

  • Contraindicated in pathologic hyperlipidemia
  • May need to reduce parenteral lipid administration
  • Expect development of hypertriglyceridemia with higher doses and longer infusions

Intravenous (IV)

  • Continuous
    • Children: 0.5-1 mcg/kg/min
      • Titrate by 0.5-1 mcg/kg/min every 2-10 min
      • Max 10 mcg/kg/min
    • Adults: 1-2 mg/h
      • Typical 4-6 mg/h
      • Max 21 mg/h

Nicardipine (Cardene®)

[UpToDate] [LPCH Lexicomp]

Intravenous (IV)

  • Continuous
    • Children: 0.2-1 mcg/kg/min
      • Titrate by 0.2-1.5 mcg/kg/min every 15-30 min
      • Max 5 mcg/kg/min
    • Adults: 5 mg/h
      • Titrate by ≤2.5 mg/h every 15 min
      • Max 15 mg/h

Beta blockers

warning

Avoid in asthma, obstructive airway disease (e.g., BPD), untreated pheochromocytoma, heart failure (especially uncompensated), heart block, sinus bradycardia

Atenolol (Tenormin®)

(β1) [UpToDate] [LPCH Lexicomp]

Enteral

  • May be dosed daily or divided BID
  • Children: 0.5-1 mg/kg/day (25-50 mg/day)
    • Usual range 0.5-1.5 mg/kg/day
    • Max 2 mg/kg/day (≤100 mg/day)
  • Adults: 25-50 mg daily
    • Max 100 mg/day

Labetalol (Trandate®)

(β1, β2, α1) [UpToDate] [LPCH Lexicomp]

note

Labetalol is also α1-antagonist (especially when given enterally)

Enteral

  • Children: 0.5-1.5 mg/kg/dose BID
    • Max 10-12 mg/kg/day (≤1200 mg/day)
  • Adults: 100 mg BID
    • Titrate by 100-200 mg BID every 2-3 days
    • Usual range 100-300 mg BID
    • Max 2400 mg/day
      tip

      If having adverse effects with BID dosing, consider TID dosing for improved tolerance (using the same total daily dose)

Intravenous (IV)

  • Intermittent
    • Children: 0.2-1 mg/kg q4-6h
      • Max 40 mg/dose
  • Continuous
    • Children: 0.25-0.5 mg/kg/h
      • Max 3 mg/kg/h

Metoprolol (Lopressor®, Toprol XL®)

(β1) [UpToDate] [LPCH Lexicomp]
Dose conversion: when switching between immediate/extended release, keep same total daily dose

Enteral

  • Immediate release
  • Age 1-17: 0.5-1 mg/kg/dose BID
    • Max 6 mg/kg/day (≤200 mg/day)
  • Extended release
    • Age ≥6: 1 mg/kg daily (≤50 mg/day)
      • Max 2 mg/kg/day (≤200 mg/day)
    • Scored extended release tablets can be halved, but do not crush/chew

Propranolol (Hemangeol, Inderal LA®, Inderal XL®, InnoPran XL®)

(β1, β2) [UpToDate] [LPCH Lexicomp]

Enteral

  • Children: 0.25-0.5 mg/kg q12h or 0.125-0.25 mg/kg q6h
    • Titrate every 5-7 days
    • Usual range 1-5 mg/kg/day
    • Max 8 mg/kg/day
  • Adults: 20-40 mg BID
    • Titrate every 3-7 days
    • Usual range 40-240 mg/day
    • Max 640 mg/day

Esmolol (Brevibloc®)

(β1) [UpToDate] [LPCH Lexicomp]

Intravenous (IV)

  • Children: 25-100 mcg/kg/min
    • Load with 100-500 mcg/kg/min over 1 min
    • Titrate by 25-50 mcg/kg/min every 5-10 min
      • Consider repeat loading dose (100-500 mcg/kg over 1 min) before each uptitration
    • Max 500 mcg/kg/min
      • Children with postoperative hypertension after cardiac surgery may require up to 1000 mcg/kg/min
  • Adults: 25-50 mcg/kg/min
    • Load with 250-500 mcg/kg/min over 1 min
    • Titrate by 50 mcg/kg/min every 5 min
      • Consider repeat loading dose (250-500 mcg/kg over 1 min) before each uptitration
    • Max 300 mcg/kg/min

Alpha agonists

Clonidine (Catapres®, Kapvay®, Nexiclon XR®)

[UpToDate] [LPCH Lexicomp]
Dose conversion: when converting between TD patch and enteral dosing, the TD patch dose is approximately equal to the total enteral daily dose used. IR (generic) and XR (Kapvay®, Nexiclon XR®) formulations are not 1:1 interchangeable; see drug labels.

Enteral

  • Age <12: 1.25-3 mcg/kg q6-8h or 2.5-5 mcg/kg q12h
    • Max 10 mcg/kg/dose or 0.9 mg/day (900 mcg/day)
  • Age ≥12: 0.05-0.1 mg/dose BID
    • Titrate every ~7 days
    • Usual range 0.2-0.4 mg/day divided BID
    • Max 2.4 mg/day

Transdermal (TD)

  • Children/Adults: 0.05-0.1 mg/24h (1/2 patch-#1 patch)
    • Must change the patch every 7 days
    • Titrate every 1-2 weeks
    • May take 2-3 days to see full effects
    • Usual range 0.1-0.3 mg/24h
    • Max 0.6 mg/day
warning

Cutting transdermal patches compromises the membrane-controlled system and can result in widely variable drug delivery [PMID 23118690]. Instead, it is recommended that an adhesive bandage be placed over the portion of the patch.

Direct vasodilators

Hydralazine (Apresoline®)

[UpToDate] [LPCH Lexicomp]

Enteral

  • 0.25 mg/kg PO q6-8h PRN
    • Max 25 mg/dose

Intravenous (IV)

  • Can also be given IM (dosed 1:1)
  • 0.1-0.2 mg/kg IV q4-6h PRN
    • Max 0.6 mg/kg/dose
      warning

      Blood pressure response to hydralazine (particularly when given IV) can be unpredictable; close monitoring is warranted

Minoxidil (Loniten®)

[UpToDate] [LPCH Lexicomp]

Enteral

  • Can be given daily or divided BID
  • Age <12: 0.1-0.2 mg/kg daily (≤5 mg/day)
    • Titrate every 3 days
    • Usual range 0.25-1 mg/kg/day
    • Max 5 mg/kg/day (≤50 mg/day)
  • Age ≥12: 5 mg/day
    • Titrate every 3 days
    • Usual range 2.5-80 mg/day
    • Max 100 mg/day

Nitroprusside

[UpToDate] [LPCH Lexicomp]

warning

Risk of methemoglobinemia as well as cyanide and thiocyanate toxicity

  • Send thiocyanate level if on drip ≥3-5 days or if rate >4 mcg/kg/min or if renal dysfunction
    • Goal thiocyanate level <1 mmol/L
  • Monitor cyanide levels in patients with hepatic dysfunction
    • Acidosis may be earliest sign of cyanide toxicity

Intravenous (IV)

  • Children/Adults: 0.3-0.5 mcg/kg/min
    • Titrate by 0.5 mcg/kg/min every 5 min
    • Recommend limiting to 3 mcg/kg/min
    • Max 10 mcg/kg/min (1 mcg/kg/min in kidney failure)
      • Manufacturer recommends avoiding the use of high doses (8-10 mcg/kg/min) for >10 minutes

Angiotensin-converting enzyme inhibitors (ACEis)

warning
  • Contraindicated in pregnancy
  • Avoid in , AKI, and (typically) CKD with GFR <30 mL/min/1.73m²
  • Start with lower doses if on diuretics/volume depleted

Enalapril (Epaned®, Vasotec®)

[UpToDate] [LPCH Lexicomp]

Enteral

  • Neonates: 0.04-0.1 mg/kg daily
    • Titrate every few days
    • Max 0.27 mg/kg/day
  • Infants/Children: 0.08 mg/kg/dose daily
    • Titrate every 1-2 weeks
    • Max 0.58 mg/kg/day (≤40 mg/day)
  • Adults: 2.5-5 mg daily
    • Titrate every 1-2 weeks
    • Max 40 mg/day

Intravenous (IV) (Enalaprilat)

[UpToDate] [LPCH Lexicomp]

  • Neonates/Infants/Children: 5-10 mcg/kg q8-24h
    • Max 1.25 mg/dose (1250 mcg/dose) in infants/children
  • Adults: 0.625-1.25 mg q6h
    • Max 5 mg/dose (20 mg/day)

Lisinopril (Qbrelis®)

[UpToDate] [LPCH Lexicomp]

Enteral

  • Infants: 0.07-0.1 mg/kg daily
    • Titrate every 2 weeks
    • Max 0.5 mg/kg/day
  • Children/Adolescents: 0.07-0.1 mg/kg daily (≤5 mg/day)
    • Titrate every 1-2 weeks
    • Max 0.6 mg/kg/day (≤40 mg/day)
  • Adults: 5-10 mg daily
    • Titrate every 1-2 weeks
    • Max 40 mg/day

Angiotensin II receptor blockers (ARBs)

warning
  • Contraindicated in pregnancy
  • Avoid in , AKI, and (typically) CKD with GFR <30 mL/min/1.73m²
  • Start with lower doses if on diuretics/volume depleted

Losartan (Cozaar®)

[UpToDate] [LPCH Lexicomp]

Enteral

  • May be dosed daily or divided BID
  • Age 6-16: 0.7 mg/kg daily (≤50 mg/day)
    • Max 1.4 mg/kg/day (≤100 mg/day)
  • Age ≥17: 25-50 mg daily
    • Max 100 mg/day

Potassium-sparing

tip

Enteral equivalents: spironolactone 12.5 mg = amiloride 5 mg = eplerenone 25 mg

Spironolactone (Aldactone®, CaroSpir®)

[UpToDate] [LPCH Lexicomp]

Enteral

warning

Liquid formulation (CaroSpir®) is not equivalent to tablet (15-37% higher serum concentration vs tablet); decrease doses by ~20% when using the liquid formulation

  • Sometimes packaged with HCTZ (Aldactazide®)
  • Neonates: 1-3 mg/kg/day
    • May dose daily or divide BID
  • Infants/Children: 1-3.3 mg/kg/day
    • May dose daily or divide into 2-4 doses
    • Max 100 mg/day
  • Adults: 12.5-25 mg q24h
    • Titrate every 2-4 weeks (weekly if severe asymptomatic hypertension)
    • Usual range 25-50 mg
    • Max 100 mg/day

Amiloride (Midamor®)

[UpToDate] [LPCH Lexicomp]

Enteral

  • May dose daily or divide BID
  • Children:
    • 0.4-0.625 mg/day (≤5 mg/day)
    • Titrate by ≤5 mg/day
    • Max 20 mg/day
  • Adults:
    • 5 mg/day
    • Titrate by ≤5 mg/day
    • Max 20 mg/day