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Hydralazine is a direct vasodilator used orally to treat essential hypertension, among other diseases, and intravenously to rapidly reduce blood pressure in hypertensive urgency or emergency. Per JNC 8 guidelines, it is not a first-line agent for the treatment of essential hypertension. This is due to hydralazine’s stimulation of the sympathetic nervous system, among several other adverse effects that make the current newer first-line agents more efficacious. This activity outlines the indications, mechanism of action, administration, contraindications, and adverse effects of hydralazine. Objectives: Identify the indications for initiating hydralazine therapy. Summarize the theorized mechanism of action of hydralazine. Discuss the parameters of hydralazine administration. Outline how an interprofessional team can coordinate the use and monitoring of hydralazine to obtain the best patient outcomes. Access free multiple choice questions on this topic.

Published reports of toxicity with acute use of hydralazine are uncommon. Signs of toxicity include hypotension, tachycardia, headaches, and generalized flushing.[21] Chronic toxicity could lead to DILE.[22] There is no specific treatment for an overdose other than supportive therapy. Fluids should be given initially, followed by vasopressors if hypotension persists despite fluid resuscitation. Tachycardia or ischemia can be treated with beta-blockers with attention to blood pressure prior to administration.[22]

Hydralazine should not be considered a first-line agent for essential hypertension, but can be considered in hypertension refractory to other first-line medications. The newer hypertensive medications are more efficacious with fewer adverse effects. The recommended dosing of 3 to 4 times daily makes hydralazine patient compliance a challenge. Patients tend to tolerate this medication better when the hydralazine is given with a beta-blocker and/or diuretic.[2] Intravenous hydralazine has had increased off-label use for the treatment of hypertensive urgency or emergency.[4] However, it should not be considered for first-line therapy due to tachyphylaxis, highly variable blood pressure, and adverse hypotension.[2] For African Americans with HFrEF, the combination of hydralazine and isosorbide dinitrate can be added to medication therapy if the patient is already receiving an ACE inhibitor, ARB, or ARNI and a beta-blocker.[6] In clinical practice, this combination has been used in heart failure patients as a preload and afterload reducer, especially in patients who cannot tolerate beta-blockers and ACE inhibitors or ARBs and would benefit from therapy reducing their systolic blood pressure.[8] While hydralazine is relatively safe, it is important to be aware of some of its adverse effects, which, although rare, include triggering lupus-like syndrome.[11] This can usually be reversed upon discontinuation of the drug.[13] An interprofessional team approach that includes clinicians, specialists, nursing staff, and pharmacists is essential for optimizing hydralazine therapy. Team members collaborate to monitor therapeutic response, identify potential adverse effects, provide patient education on appropriate dosing and signs of toxicity, assess for drug–drug interactions, and communicate concerns to the prescribing provider. This coordinated strategy supports safer prescribing practices and is associated with improved clinical outcomes.