What medication should be given to a patient with hypertension on Norvasc (amlodipine) and Losartan with cocaine use?

Management of Hypertension in a Patient with Cocaine Use on Amlodipine and Losartan

For a patient with elevated blood pressure who uses cocaine and is currently on amlodipine (Norvasc) and losartan, benzodiazepines alone or in combination with nitroglycerin are the recommended medications for management of hypertension. 1

First-Line Treatment Options

• Benzodiazepines (such as diazepam or lorazepam) should be administered as first-line therapy for cocaine-induced hypertension due to their ability to reduce central and peripheral manifestations of cocaine intoxication 1
• Nitroglycerin can be added to benzodiazepines for more effective blood pressure control and has been shown to reverse cocaine-associated coronary vasoconstriction 1
• The combination of benzodiazepines with nitroglycerin is particularly effective for managing both the hypertension and tachycardia associated with acute cocaine intoxication 1

Medications to Consider for Persistent Hypertension

• Calcium channel blockers (such as nicardipine, clevidipine, or verapamil) can be considered if hypertension persists after benzodiazepines and nitroglycerin 1
• Phentolamine, an alpha-adrenergic antagonist, may be useful for treating cocaine-associated hypertension by reversing cocaine-induced coronary artery vasoconstriction 1
• Vasodilators like nitroprusside can be considered in cases of severe hypertension not responding to first-line therapies 1

Medications to Avoid

• Beta-blockers (including labetalol) should NOT be administered to patients with cocaine intoxication due to the risk of unopposed alpha-adrenergic stimulation, which can worsen coronary vasospasm and potentially increase blood pressure 1, 2
• This contraindication applies even though the patient is already on amlodipine and losartan, as beta-blockers can still cause paradoxical hypertension in the setting of cocaine use 1, 2
• The risk of beta-blocker use is particularly high during acute cocaine intoxication (presenting with euphoria, tachycardia, and/or hypertension) 1

Monitoring and Follow-up

• Continuous cardiac monitoring is essential during treatment to detect potential arrhythmias or other cardiovascular complications 1
• Target blood pressure reduction should be gradual, aiming for a 20-25% reduction in mean arterial pressure within the first hour 3
• The patient's current medications (amlodipine and losartan) can be continued as they are appropriate agents for long-term management of hypertension in patients with cocaine use 4, 5

Special Considerations

• Assess for end-organ damage including myocardial ischemia, as cocaine can cause coronary vasospasm and accelerated atherosclerosis 1
• Consider that approximately 13% of emergency department patients with severe hypertension (diastolic BP ≥120 mmHg) may have recent cocaine use, even if not initially reported 6
• For long-term management, amlodipine/losartan combination therapy has shown good blood pressure control in hypertensive patients, with target blood pressure attainment rates above 90% 5

Treatment Algorithm

1. First: Administer benzodiazepines (e.g., diazepam 5-10 mg IV) 1
2. If hypertension persists: Add nitroglycerin (IV or sublingual) 1
3. For refractory hypertension: Consider calcium channel blockers (nicardipine or clevidipine) or phentolamine 1
4. Avoid all beta-blockers, including labetalol, due to risk of worsening hypertension 1, 2
5. Continue current amlodipine and losartan therapy for long-term management 4, 5