What should be added to lisinopril (angiotensin-converting enzyme inhibitor) 20 mg and amlodipine (calcium channel blocker) 10 mg for a client with elevated blood pressure and tachycardia, who also uses cocaine?

Management of Hypertension in a Cocaine User on Lisinopril and Amlodipine

For a client with elevated blood pressure and tachycardia on lisinopril 20 mg and amlodipine 10 mg who uses cocaine, adding a benzodiazepine is the most appropriate next step in management.

Understanding the Clinical Situation

The patient presents with:

• Current medications: Lisinopril 20 mg (ACE inhibitor) and Amlodipine 10 mg (calcium channel blocker)
• Ongoing cocaine use
• Elevated blood pressure despite maximum doses of both medications
• Tachycardia (HR >100 bpm)

Recommended Treatment Approach

First-Line Addition: Benzodiazepines

1. Add a benzodiazepine (e.g., diazepam or lorazepam)
   • Benzodiazepines are the mainstay of initial management for cocaine-induced hypertension and tachycardia 1, 2
   • They reduce sympathetic tone and agitation, addressing the underlying mechanism of cocaine-induced cardiovascular effects
   • They help mitigate the hyperadrenergic state caused by cocaine

Medication Considerations and Contraindications

1. Avoid beta-blockers as monotherapy

   • Beta-blockers alone are contraindicated in cocaine users due to the risk of unopposed alpha-adrenergic stimulation 1, 3, 4
   • This can paradoxically worsen hypertension and coronary vasospasm 4

2. Consider vasodilator options only after benzodiazepines

   • Nitrates can be considered for persistent hypertension or chest pain 1, 2
   • Phentolamine (alpha-blocker) may be beneficial for severe hypertension 1, 2

3. Combined alpha/beta blockers only after vasodilator administration

   • Labetalol may be reasonable only after a vasodilator has been administered within the previous hour 1
   • This approach minimizes the risk of unopposed alpha stimulation

Monitoring and Additional Management

1. Cardiovascular monitoring

   • Regular ECG monitoring for dynamic changes
   • Monitor for signs of cocaine-induced coronary vasospasm
   • Check troponin levels if chest pain or ECG changes are present 2

2. Address substance use

   • Recommend cessation of cocaine use
   • Consider referral to addiction treatment services
   • Educate about cardiovascular risks of continued cocaine use 2

Treatment Algorithm

1. Initial step: Add benzodiazepine
2. If BP remains elevated: Consider additional vasodilators (nitrates)
3. If vasospasm is suspected: Increase calcium channel blocker dose (though amlodipine is already at maximum)
4. For persistent tachycardia after vasodilator: Consider combined alpha/beta blocker (labetalol)
5. For severe, refractory hypertension: Consider phentolamine

Pitfalls to Avoid

• Never use pure beta-blockers (e.g., propranolol, metoprolol) as they can worsen hypertension in cocaine users 3, 4
• Don't overlook the need for substance use treatment alongside BP management
• Avoid assuming that standard hypertension protocols apply to patients using cocaine
• Don't dismiss tachycardia as it may indicate ongoing cocaine effect or withdrawal

The combination of cocaine use with hypertension creates a unique clinical scenario requiring specific management approaches that differ from standard hypertension treatment protocols. Addressing both the acute cardiovascular effects and the underlying substance use is essential for effective management.