From the Guidelines
For cocaine-induced hypertension in the emergency department, benzodiazepines are the first-line treatment, as they effectively reduce sympathetic stimulation and alleviate hypertension. According to the most recent guidelines, benzodiazepines should be administered first to manage cocaine-induced hypertension 1. The recommended dosage is lorazepam 1-2 mg IV or diazepam 5-10 mg IV.
If hypertension persists after benzodiazepines, the following options can be considered:
- Phentolamine 5 mg IV, a competitive alpha-receptor blocking agent, can be used to counteract cocaine's vasoconstrictive effects 1
- Nitroglycerin 0.4 mg SL/spray or 5-10 mcg/min IV can be used as an alternative to phentolamine 1
- Calcium channel blockers like nicardipine (5 mg/hr IV) or clevidipine (1-2 mg/hr IV) can be used as second-line agents 1
It is essential to avoid beta-blockers (like metoprolol or propranolol) as they can worsen hypertension by leaving alpha-adrenergic effects unopposed, potentially causing coronary vasoconstriction and increased blood pressure 1. Labetalol, despite having alpha and beta blocking properties, should also be avoided due to its stronger beta effects 1.
Patients should be monitored for at least 4-6 hours after symptom resolution, with cardiac monitoring and serial vital signs, as cocaine's effects can persist or recur. The management of cocaine-induced hypertension should prioritize reducing sympathetic stimulation and alleviating vasoconstrictive effects, while avoiding medications that may exacerbate the condition 1.
From the FDA Drug Label
For preoperative reduction of elevated blood pressure, 5 mg of phentolamine mesylate (1 mg for children) is injected intravenously or intramuscularly 1 or 2 hours before surgery, and repeated if necessary During surgery, phentolamine mesylate (5 mg for adults, 1 mg for children) is administered intravenously as indicated, to help prevent or control paroxysms of hypertension, tachycardia, respiratory depression, convulsions, or other effects of epinephrine intoxication
The answer to the question of using phentolamine as an anti-hypertensive medication in the ED for cocaine-induced hypertension is:
- Phentolamine can be used to prevent or control hypertensive episodes.
- The recommended dose is 5 mg intravenously for adults.
- It can help prevent or control paroxysms of hypertension, tachycardia, respiratory depression, convulsions, or other effects of epinephrine intoxication 2.
From the Research
Cocaine-Induced Hypertension
- Cocaine abuse can lead to hypertension, tachycardia, and other cardiovascular issues 3, 4
- The use of beta-blockers, such as propranolol, can worsen hypertension in cocaine-intoxicated patients due to unopposed alpha-stimulation 5, 6
Treatment Options
- Benzodiazepines and other GABA-active agents may be effective in treating cocaine-induced hypertension and tachycardia, but may not always mitigate these symptoms 3
- Calcium channel blockers may decrease hypertension and coronary vasospasm, but not necessarily tachycardia 3
- Nitric oxide-mediated vasodilators, such as nitroglycerin, may lead to severe hypotension and reflex tachycardia 3
- Alpha-adrenoceptor blocking drugs, such as prazosin, may improve hypertension and vasospasm, but not tachycardia 7, 4
- Mixed beta-/alpha-blockers, such as labetalol and carvedilol, may be effective in treating cocaine-induced hypertension and tachycardia without causing unopposed alpha-stimulation 3, 6
Pharmacological Treatment
- The treatment of cocaine-induced hypertension and cardiovascular toxicity should be guided by the patient's specific symptoms and medical history 3
- A cautious approach to the use of beta-blockers in patients with cocaine intoxication is recommended due to the risk of unopposed alpha-stimulation 5, 6
- Further research is needed to evaluate the effectiveness of different pharmacological treatments for cocaine-induced hypertension and cardiovascular toxicity 3, 6