What benzodiazepines are used to treat acute cocaine intoxication?

Benzodiazepines for Acute Cocaine Intoxication

Benzodiazepines, particularly diazepam and lorazepam, are the first-line treatment for acute cocaine intoxication due to their effectiveness in managing agitation, hypertension, tachycardia, and preventing seizures. 1, 2

Mechanism of Action and Benefits

Benzodiazepines work by:

• Enhancing GABA-mediated inhibition in the central nervous system
• Counteracting the sympathomimetic effects of cocaine
• Reducing cardiovascular complications
• Preventing seizures

Specific Benzodiazepines Recommended

1. Diazepam:

   • First-line agent for cocaine intoxication 2
   • Effective for managing agitation and preventing seizures
   • Longer duration of action compared to other benzodiazepines

2. Lorazepam:

   • Alternative first-line agent 1, 2
   • Particularly useful in patients with liver dysfunction
   • More predictable absorption when given intramuscularly

Dosing Considerations

• Initial dosing:
  • Diazepam: 5-10 mg IV/IM
  • Lorazepam: 2-4 mg IV/IM
• Doses can be repeated every 5-15 minutes until adequate sedation is achieved
• Titrate to clinical effect (reduction in agitation, normalization of vital signs)

Clinical Applications

Benzodiazepines are particularly indicated for:

1. Cardiovascular manifestations:

   • Hypertension and tachycardia 1
   • Can be used alone or in combination with nitroglycerin for management of cocaine-induced hypertension 1

2. Neuropsychiatric manifestations:

   • Agitation and psychomotor hyperactivity 1, 2
   • Seizures or seizure prevention 1

3. Hyperthermia:

   • As adjunctive therapy alongside rapid external cooling 1

Combination Therapy

For specific complications, benzodiazepines may be combined with:

• Nitroglycerin: For persistent hypertension or coronary vasospasm 1
• Sodium bicarbonate: For wide-complex tachycardia or QRS prolongation 1
• Calcium channel blockers: For refractory hypertension or coronary vasospasm 1

Cautions and Contraindications

• Respiratory depression (monitor closely)
• Paradoxical reactions (rare)
• Avoid beta-blockers in acute cocaine intoxication due to risk of unopposed alpha stimulation and worsening coronary vasospasm 1

Evidence Strength

The recommendation for benzodiazepines is supported by:

• Multiple clinical guidelines (Class IIa, LOE B) 1
• Systematic reviews of animal models showing 52% absolute risk reduction in mortality compared to placebo 3
• Experimental studies demonstrating efficacy in alleviating cocaine-induced anxiety 4, 5

Key Takeaways

1. Benzodiazepines are the cornerstone of management for acute cocaine intoxication
2. They effectively address multiple manifestations including agitation, hypertension, tachycardia, and seizures
3. Diazepam and lorazepam are the most commonly recommended agents
4. Dosing should be titrated to clinical effect
5. Combination therapy may be necessary for specific complications

Remember that the primary goal of treatment is to reduce morbidity and mortality by addressing the sympathomimetic toxidrome and preventing life-threatening complications such as seizures, hyperthermia, and cardiovascular events.