Can a patient who has recently used cocaine be administered a beta blocker (beta-adrenergic blocking agent)?

From the Guidelines

Beta blockers should be avoided in patients who have recently used cocaine due to the risk of potentiating coronary spasm. Using beta blockers in this situation can potentially worsen the cardiovascular effects of cocaine by allowing unopposed alpha-adrenergic stimulation, which can increase blood pressure and potentially lead to coronary vasoconstriction, as noted in the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1. This occurs because cocaine blocks the reuptake of catecholamines (like norepinephrine), stimulating both alpha and beta receptors. When beta receptors are blocked but alpha receptors remain stimulated, blood vessels can constrict further, potentially worsening hypertension and reducing coronary blood flow. Some key points to consider in managing patients with recent cocaine use include:

• If treatment for hypertension or tachycardia is needed, benzodiazepines (like lorazepam 1-2 mg IV) should be first-line therapy to reduce sympathetic stimulation, as they have been useful for management of hypertension and tachycardia owing to their effects on the central and peripheral manifestations of acute cocaine intoxication 1.
• For persistent hypertension, calcium channel blockers such as nicardipine or clevidipine are preferred.
• Alpha-blockers like phentolamine may be considered in severe cases.
• If chest pain is present, nitroglycerin can help with coronary vasodilation. Only consider beta blockers after cocaine has been cleared from the system, typically at least 24-48 hours after last use. It is essential to prioritize the patient's safety and avoid potential harm from beta blocker use in the context of recent cocaine use, as emphasized by the guideline's Class III: Harm recommendation against administering beta blockers to patients with ACS with a recent history of cocaine or methamphetamine use who demonstrate signs of acute intoxication 1.

From the Research

Cocaine and Beta Blocker Use

• The use of beta blockers in patients who have recently used cocaine is a topic of debate, with some studies suggesting that it may be safe and effective, while others warn of potential risks 2, 3, 4.
• A systematic review and meta-analysis found that beta blocker use was not associated with adverse clinical outcomes in patients presenting with acute chest pain related to cocaine use 4.
• However, another study suggested that the use of beta blockers in cocaine-positive patients may lead to unopposed α-stimulation, which can worsen cardiovascular toxicity 3.
• The American College of Cardiology/American Heart Association guidelines recommend avoiding beta blockers in the setting of cocaine-associated acute coronary syndrome, but the evidence for this recommendation is limited 2.

Alternative Treatments

• Other treatments that have been shown to be effective in managing cocaine-induced cardiovascular toxicity include benzodiazepines, calcium channel blockers, and nitric oxide-mediated vasodilators 2, 5, 6.
• Benzodiazepines may help to reduce agitation and anxiety, while calcium channel blockers can help to decrease hypertension and coronary vasospasm 2.
• Nitroglycerin has been shown to be safe and effective in the treatment of cocaine-associated chest pain, and may be a useful alternative to beta blockers 6.

Clinical Considerations

• When treating a patient who has recently used cocaine, it is essential to consider the individual's specific clinical presentation and medical history 2, 5.
• The use of beta blockers should be carefully weighed against the potential risks and benefits, and alternative treatments should be considered if possible 3, 4.
• Further research is needed to fully understand the effects of beta blockers in patients with cocaine-induced cardiovascular toxicity, and to develop evidence-based guidelines for treatment 2, 4.