Clin drug invest 2005; 25 (5): 353-354

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CASE REPORT
 2005 Adis Data Information BV. All rights reserved.
Transforaminal Epidural Injection
Induces Hypertensive Crisis in a
Patient whose Nifedipine
was Withdrawn
L. Margolin, L. Tuluca and R. Kaylakov
Department of Physical Medicine and Rehabilitation, Bronx, New York, USA Hundreds of thousands of patients undergo inter- Since transforaminal epidural injections require ventional pain management procedures annually in- that the patient remains alert and oriented during the cluding transforaminal spinal epidural injections.
procedure in order to monitor patient response, she The majority of these patients are ≥50 years of age did not receive any sedation or analgesia before the and have a history of hypertension. The procedure procedure. The long waiting time as well as prepara- requires that the patient remains alert and oriented tions for the injection in the operating room resulted throughout in order to monitor the pain relief pattern in significant agitation in the patient, and she report- and the patient’s response. In this setting special ed having a headache immediately after the proce- considerations should be applied to achieve proper dure started. At that point the patient had a blood pre- and perioperative blood pressure control.
pressure of 210/112mm Hg, which subsequentlyincreased over 10 minutes to 224/116mm Hg, and apulse of 110 beats/minute (i.e. sinus tachycardia), a 1. Case Report
respiratory rate of 18 breaths/minute andhaemoglobin saturation of 97%.
A 54-year-old obese Hispanic female, with a past The procedure was stopped and the patient’s medical history of hypertension controlled by blood pressure was partially controlled over several nifedipine 30mg daily, with low back pain was hours by orally administered clonidine until referred for right spinal L4/L5 level transforaminal nifedipine had been restarted and absorbed.
epidural injection for low back pain relief.
The patient had previously undergone a left L4/ 2. Discussion
L5 level transforaminal epidural injection while re-ceiving nifedipine without complications. The pa- Nifedipine has been shown to cause upregulation tient did not have any other significant past medical of functionally active cardiac calcium channels after history, including cardiac and pulmonary problems.
administration, which offers a possible explanation The patient had been erroneously instructed by for a ‘withdrawal effect’ after discontinuation oftreatment with this drug.[1] the nursing staff to discontinue nifedipine on the daybefore the injection procedure, which the patient A recent study that compared nifedipine with did. On the day of the procedure the patient was amlodipine showed that although amlodipine was asymptomatic. She travelled from a distance and found to be more effective, no differences in safety arrived at the hospital 5 hours before the scheduled parameters were observed, and neither drug caused any serious or severe treatment-related adverse events. Amlodipine provided greater protection than Awareness by the practitioner of nifedipine with- nifedipine gastrointestinal therapeutic system drawal is strongly advocated, particularly for proce- (GITS) against loss of blood pressure control fol- dures that require minimal sedation and cause sig- nificant patient anxiety such as spinal trans- Nifedipine has been found to be an effective and foraminal epidural injections. There is no medical well tolerated antihypertensive for essential hyper- justification for stopping the medication prior to the tension, although it is not considered to be the drug of choice for this condition.[3] Nifedipine has beenreported to cause mild adverse effects such as dizzi- References
ness, flushing and headache (more frequent with the 1. Morgan PE, Aiello EA, Chiappe de Cingolani GE, et al. Chronic immediate-release formulation [incidence of administration of nifedipine induces up-regulation of function-al calcium channels in rat myocardium. J Mol Cell Cardiol 23–27%]) constipation and nausea (11%), and heart- 2. Ongtengco I, Morales D, Sanderson J, et al. Persistence of the antihypertensive efficacy of amlodipine and nifedipine GITS Our patient had been taking nifedipine for more after two ‘missed doses’: a randomised, double-blind compara- than 3 years without significant adverse effects. In tive trial in Asian patients. J Hum Hypertens 2002 Nov; 16 our case, the combination of anxiety, ‘white coat’ 3. Pivac N, Naranca M, Vujic-Podlipec D, et al. Prospective con- hypertension and nifedipine withdrawal caused a trolled trial of two nifedipine extended release formulations in severe hypertensive crisis. Our case is also sup- the treatment of essential hypertension. Arzneimittel For-schung 2002; 52 (5): 379-84 ported by the work of Bursztyn et al., who reported a 4. Bursztyn M, Tordjman K, Grossman E, et al. Hypertensive hypertensive crisis of 300/200mm Hg with abrupt crisis associated with nifedipine withdrawal. Arch Intern Med  2005 Adis Data Information BV. All rights reserved.

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