A 58-year-old man who had been taking clonidine 0.3 mg twice daily ran out of his medication three days ago. He now presents with BP 245/148 mmHg, marked anxiety, tremor, piloerection, diaphoresis, and palpitations. There is no focal neurological deficit and no chest pain. Which is the most appropriate immediate management?

• A Restart clonidine orally or via transdermal patch, with IV labetalol added if rapid control is needed ✓
• B Sublingual nifedipine repeated every 30 minutes
• C IV furosemide infusion
• D IV enalaprilat infusion

Explanation

Abrupt cessation of a central alpha-2 agonist causes rebound sympathetic overactivity with noradrenaline release, producing exactly this picture of extreme hypertension, tremor, and sweating. The definitive treatment is rechallenge with clonidine, which restores central sympathetic suppression; IV labetalol provides useful adjunctive control. Sublingual nifedipine is obsolete in hypertensive emergencies because its unpredictable absorption causes precipitous hypotension and reflex ischemia. Diuretics and ACE inhibitors do not address the mechanism and are ineffective for this rebound state.

Reference: Katzung's Basic and Clinical Pharmacology, 15th ed.

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