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Pharmacologic treatment and prevention of high altitude illness (HAI)

Condition		Preferred agent	Alternatives
AMS/HACE	Prevention*	Acetazolamide: 125 mg orally every 12 hours Children: 2.5 mg/kg (maximum single dose: 125 mg) orally every 12 hours^¥ Duration: Start day before ascent and continue 2 to 3 days at maximum altitude; may use once at night thereafter to improve sleep	Dexamethasone: 2 mg orally every 6 hours or 4 mg orally every 12 hours Children: Acetazolamide preferred; do not use for prophylaxis Duration: Start day of ascent and continue 2 to 3 days at maximum altitude but for no more than 7 days total
	Treatment of mild AMS^¶	Acetazolamide: 125 to 250 mg orally every 12 hours Children: 2.5 mg/kg (maximum single dose: 250 mg) orally every 12 hours^¥ Duration: Continue for 24 hours after symptoms resolve or descent completed	Dexamethasone: 2 to 4 mg orally every 6 hours Children: 0.15 mg/kg (maximum single dose: 4 mg) orally every 6 hours Duration: Continue until 24 hours after symptoms resolve or descent completed but for no more than 7 days total
	Treatment of moderate to severe AMS	Dexamethasone:^Δ 4 mg orally every 6 hours Children: 0.15 mg/kg (maximum single dose: 4 mg) orally every 6 hours Duration: Continue for 24 hours after symptoms resolve or descent completed but for no more than 7 days total	Acetazolamide: 125 to 250 mg orally every 12 hours Children: 2.5 mg/kg (maximum single dose: 250 mg) orally every 12 hours^¥ Duration: Continue for 24 hours after symptoms resolve or descent completed
	Treatment of HACE	Dexamethasone:^Δ 8 to 10 mg orally /IM/IV once, then 4 mg orally/IM/IV every 6 hours Children: 0.15 mg/kg (maximum single dose: 4 mg) every 6 hours Duration: Continue until 24 hours after symptoms resolve or descent completed but for no more than 7 days total	Acetazolamide: 250 mg orally every 12 hours; may use as adjunct with dexamethasone; not for monotherapy Children: 2.5 mg/kg (maximum single dose: 250 mg) orally every 12 hours^¥ Duration: Continue until 24 hours after symptoms resolve or descent completed
HAPE	Prevention*	Nifedipine: 60 mg extended-release orally divided daily (30 mg orally every 12 hrs; or 20 mg orally every 8 hours)^◊ Children: 0.5 mg/kg (maximum single dose: 20 mg) extended-release orally every 8 hours^◊ Duration: Start day before ascent and continue for 5 days at maximum altitude	Further research is needed before the medications listed below can be recommended for routine use in HAPE prevention: Tadalafil: 10 mg orally every 12 hours; start day of ascent and continue 3 to 5 days at maximum altitude Sildenafil: 50 mg orally every 8 hours; start day of ascent and continue 3 to 5 days at maximum altitude Dexamethasone: 8 mg orally every 12 hours; start day of ascent and continue 48 to 72 hours at maximum altitude Acetazolamide: 125 to 250 mg orally every 12 hours; start day before ascent and continue 48 to 72 hours at maximum altitude
HAPE	Treatment^§	Nifedipine: 60 mg extended-release orally divided daily (30 mg orally every 12 hours or 20 mg orally every 8 hours)^◊ Children: 0.5 mg/kg (maximum single dose: 20 mg) extended-release orally every 8 hours^◊ Duration: Continue until descent completed, symptoms resolved, and SpO₂ normal for altitude	Further research is needed before the medications listed below can be recommended for routine use in HAPE treatment: Tadalafil: 10 mg orally every 12 hours Sildenafil: 50 mg orally every 8 hours Duration: Continue until descent completed, symptoms resolved, and SpO₂ normal for altitude

AMS: acute mountain sickness; HACE: high altitude cerebral edema; HAPE: high altitude pulmonary edema; IM: intramuscular; NSAID: nonsteroidal antiinflammatory drug; HAI: high-altitude illness; SpO₂: oxygen saturation.

* Gradual ascent is the best strategy for prevention of HAI. Early recognition of symptoms and prompt treatment are critical to reduce risk of progression to serious HAI (such as HAPE and HACE). Reserve pharmacologic prophylaxis for patients who have a history of HAPE or recurrent AMS and patients at high risk (as well as selected patients at moderate risk) of developing AMS/HACE according to criteria listed in the separate UpToDate content. Provision of these medications for "rescue" treatment is also reasonable.

¶ May not require pharmacologic treatment. Rest, halt ascent, and symptomatic treatment (eg, acetaminophen or NSAID for headache and ondansetron for nausea/vomiting) may be sufficient. Refer to accompanying UpToDate text.

Δ Treatment with dexamethasone alleviates symptoms of AMS/HACE but does not improve acclimatization. Dexamethasone is not a substitute for immediate descent in HACE.

◊ In United States the lowest strength extended-release nifedipine oral preparation available is 30 mg. In some other countries, 10 and 20 mg extended-release preparations are available.

§ May not require any pharmacologic intervention. In proper setting, rest and supplemental oxygen may be sufficient. Refer to accompanying UpToDate text.

¥ For immediate administration in children, a liquid acetazolamide solution can be made by crushing a 125 mg or 250 mg tablet and suspending it in cherry, chocolate, or other flavored syrup to hide the bitter taste. A flavored oral suspension useful in patients who cannot swallow pills or for measurement of doses used in smaller children (eg <125 mg) can also be compounded by a pharmacy. Detail is available in the acetazolamide pediatric drug monograph.

Courtesy of Scott Gallagher, MD and Peter Hackett, MD, with additional data from:

Luks AM, Auerbach PS, Freer L, et al. Wilderness Medical Society Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update. Wilderness Environ Med 2019; 30:S3.
Pollard A, Niermeyer S, Barry P, et al. Children at high altitude: an international consensus statement by an ad hoc committee of the International Society for Mountain Medicine, March 12, 2001. High Alt Med Biol 2001; 2:389.

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