What is the treatment for hypertension (HTN) caused by cocaine use?

Treatment of Cocaine-Induced Hypertension

Benzodiazepines are the first-line treatment for cocaine-induced hypertension, as they address the underlying sympathetic nervous system activation that drives the hypertensive crisis. 1, 2

Initial Management Algorithm

Step 1: Benzodiazepines First

• Administer lorazepam 2-4 mg IV or diazepam 5-10 mg IV immediately to reduce central nervous system stimulation and sympathetic drive 2
• Benzodiazepines alone may control both hypertension and tachycardia by addressing the root cause of cocaine toxicity 1, 2
• This approach is recommended by both the European Society of Cardiology and American Heart Association as initial therapy 1, 2

Step 2: Add Vasodilators if Needed

If severe hypertension persists after benzodiazepines, add one of the following vasodilators 1, 2:

• Phentolamine (α-blocker): 5 mg IV bolus, repeat every 10 minutes as needed—specifically indicated for catecholamine excess 2
• Nicardipine or clevidipine (calcium channel blockers): Effective for counteracting cocaine's vasoconstrictive effects 1, 2, 3
• Nitroglycerin: Start at 5 mcg/min, increase by 5 mcg/min every 3-5 minutes (maximum 20 mcg/min)—particularly useful if concurrent chest pain or coronary vasospasm is present 1, 2

Step 3: Alternative Options

• Clonidine can be used as it provides both sympathicolytic and sedative effects 1
• Nitroprusside is an option for refractory hypertension 1

Critical Contraindications

Beta-Blockers: Avoid or Use with Extreme Caution

• Pure β-blockers (propranolol, esmolol) are contraindicated because they cause unopposed α-adrenergic stimulation, leading to paradoxical worsening of hypertension and coronary vasospasm 1, 2, 4
• This has been documented to cause dangerous blood pressure spikes requiring nitroprusside rescue 4
• Labetalol (combined α/β-blocker) should only be used AFTER vasodilation has been established with nitroglycerin or a calcium channel blocker 1, 2
• The American College of Cardiology specifically warns against β-blockers during acute cocaine intoxication (signs: euphoria, tachycardia, hypertension) 1

Special Considerations

If Coronary Ischemia is Present

• Add nitroglycerin and aspirin alongside benzodiazepines 1
• Consider percutaneous coronary intervention in high-risk patients with ST-segment elevation myocardial infarction 1

If Wide-Complex Tachycardia Develops

• Administer sodium bicarbonate to counteract cocaine's sodium channel blocking effects 2

If Hyperthermia is Present

• Implement rapid cooling measures immediately, as hyperthermia can be life-threatening in cocaine toxicity 2

Monitoring Requirements

• Establish continuous cardiac monitoring and IV access 2
• Monitor vital signs closely, especially in patients with cardiovascular complications 5, 2
• Avoid β-blockers within 72 hours of cocaine use due to coronary vasospasm risk 5, 2

Common Pitfalls to Avoid

1. Never use pure β-blockers alone—this is the most dangerous error, causing unopposed α-stimulation and worsening hypertension 1, 2, 4
2. Don't skip benzodiazepines—jumping straight to antihypertensives without addressing the sympathetic surge is less effective 1, 2
3. Watch for nitroglycerin-induced hypotension—it can cause severe hypotension and reflex tachycardia 3
4. Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) unless treating tachyarrhythmias under close ECG monitoring 1