From the Guidelines
For patients using alcohol and cocaine, calcium channel blockers (CCBs) like amlodipine (5-10 mg daily) are generally the preferred first-line antihypertensive agents. Beta-blockers should be avoided as they can cause unopposed alpha-adrenergic stimulation during cocaine use, potentially worsening hypertension and increasing the risk of coronary vasoconstriction 1. ACE inhibitors or ARBs may be considered as alternatives if CCBs are contraindicated. When treating these patients, it's essential to address the underlying substance use disorders alongside blood pressure management. Cocaine causes hypertension through intense sympathetic stimulation and vasoconstriction, while chronic alcohol use can lead to resistant hypertension through multiple mechanisms including increased sympathetic activity and cortisol production. Regular monitoring is crucial as substance use patterns may affect blood pressure control and medication efficacy. The patient should be encouraged to reduce or eliminate cocaine and excessive alcohol use as part of comprehensive blood pressure management.
Some key points to consider when managing these patients include:
- The importance of limiting alcohol intake to ≤1 drink daily for women and ≤2 drinks for men, as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 2
- The need to discontinue or avoid use of recreational drugs like cocaine, as they can cause elevated blood pressure and increase the risk of cardiovascular disease 2
- The potential benefits of using benzodiazepines, CCBs, α1-adrenergic receptor antagonists, and nitrates to manage severe cocaine-induced hypertension and chest pain, as suggested by the 2023 American Heart Association focused update 1
- The importance of individualized treatment approaches, taking into account the patient's specific substance use patterns, medical history, and other factors that may affect blood pressure control and medication efficacy.
Overall, a comprehensive approach that addresses both the patient's substance use disorders and their blood pressure management is essential for improving outcomes and reducing the risk of morbidity and mortality in this population.
From the FDA Drug Label
The recommended initial dose is 10 mg once a day. The usual starting dose of losartan is 50 mg once daily.
The FDA drug label does not answer the question.
From the Research
Acceptable Starting Blood Pressure Agents
- Angiotensin-Converting Enzyme (ACE) inhibitors may be a suitable option for patients who drink alcohol and use cocaine, as they have been shown to reduce alcohol consumption 3 and may help mitigate the cardiovascular effects of cocaine use 4.
- The use of ACE inhibitors, such as fosinopril, has been studied in patients with HIV and cocaine abuse, and has been found to be well-tolerated and potentially effective in reducing cocaine use 4.
- However, it is essential to note that ACE inhibitors may not be the best choice for all patients, as they can be associated with adverse events such as cough and angioedema 5.
- In patients who are non-toxic and have a normal arterial pressure and heart rate, general anesthesia can be safely administered, even if they have a positive urine test for cocaine metabolites 6.
- The combination of alcohol and cocaine can have greater-than-additive effects on heart rate and blood pressure, and may increase the risk of violent behaviors 7.
Key Considerations
- The initial level of activity in the renin-angiotensin system may determine the effectiveness of ACE inhibitors in reducing alcohol intake 3.
- The use of ACE inhibitors should be carefully considered in patients with a history of alcohol and cocaine use, and should be monitored closely for potential adverse events 5.
- The formation of cocaethylene, a potent cardiotoxic compound, can occur when alcohol and cocaine are used together, and may increase the risk of cardiovascular complications 7.