What is the treatment for cocaine-induced hypertension?

Treatment of Cocaine-Induced Hypertension

Benzodiazepines are the first-line treatment for cocaine-induced hypertension, as they address the underlying central nervous system stimulation driving sympathetic surge; if severe hypertension persists after adequate benzodiazepine dosing, add a vasodilator such as phentolamine, nicardipine, or nitroglycerin. 1

Initial Management: Benzodiazepines First

• Administer lorazepam 2-4 mg IV or diazepam 5-10 mg IV immediately as first-line therapy to reduce central nervous system stimulation and sympathetic drive 1, 2
• Benzodiazepines often resolve both hypertension and tachycardia without requiring additional agents, as they counteract the root cause of cocaine's cardiovascular toxicity 1, 3
• The American Heart Association classifies benzodiazepines as Class IIa (beneficial) for cocaine-induced cardiovascular toxicity, though evidence is primarily extrapolated from case series rather than randomized trials 2, 4

Important caveat: Benzodiazepines may not always effectively control severe hypertension in all patients, necessitating additional vasodilator therapy 4

If Hypertension Persists: Add Vasodilators

Alpha-Blocker Option

• Phentolamine 5 mg IV bolus is specifically indicated for catecholamine-excess states like cocaine toxicity; repeat every 10 minutes as needed to achieve blood pressure target 1, 5
• Phentolamine has demonstrated reversal of cocaine-induced coronary artery vasospasm in human studies 5

Calcium Channel Blocker Options

• Nicardipine or clevidipine effectively manage cocaine-induced hypertension by counteracting vasoconstrictive effects without the risks of beta-blockade 1, 5
• Verapamil has shown resolution of cocaine-induced coronary artery vasospasm in human volunteers 5
• Calcium channel blockers may decrease hypertension and coronary vasospasm but not necessarily tachycardia 4

Nitroglycerin

• Start at 5 mcg/min IV, increase by 5 mcg/min every 3-5 minutes to maximum 20 mcg/min 1
• Particularly useful if concurrent chest pain or coronary vasospasm is present 1
• Nitroglycerin reversed cocaine-induced coronary artery vasospasm in clinical trials, with 45% of patients reporting chest pain reduction 5

Critical warning: Nitroglycerin may cause severe hypotension and reflex tachycardia in some patients 4

Alternative Agent: Dexmedetomidine

• Low-dose dexmedetomidine 0.4 µg/kg IV abolished cocaine-induced increases in sympathetic nerve activity, vascular resistance, and blood pressure without affecting heart rate 6
• This represents a novel central sympatholytic approach for cocaine-induced hypertension 6

Important limitation: Higher doses (1 µg/kg) intended to control heart rate caused paradoxical blood pressure increases in 4 of 12 subjects and should be avoided 6

Critical Contraindications

Pure Beta-Blockers: AVOID

• Never use propranolol, metoprolol, or esmolol in cocaine toxicity 1, 2
• Pure beta-blockers cause unopposed alpha-adrenergic stimulation, worsening coronary vasospasm and hypertension 1, 2, 7
• A case report documented propranolol-induced paroxysmal hypertension requiring nitroprusside rescue in cocaine intoxication 7
• Esmolol showed no consistent improvement and caused adverse effects (hypertension, hypotension, CNS depression) in 3 of 7 patients 5

Combined Alpha-Beta Blockers: Use With Extreme Caution

• Labetalol or carvedilol should only be used after alpha blockade or vasodilation is established 1, 2
• While studies in cocaine users showed labetalol and carvedilol attenuated blood pressure increases without apparent adverse effects, they should not be first-line agents 5
• The cumulative dose of labetalol should not exceed 800 mg/24 hours to prevent complications 5

Treatment Algorithm Summary

1. Secure airway, breathing, circulation; establish IV access and continuous cardiac monitoring 1
2. Administer benzodiazepines first (lorazepam 2-4 mg IV or diazepam 5-10 mg IV) 1, 2
3. Reassess blood pressure after 5-10 minutes
4. If severe hypertension persists, add vasodilator:
   • Phentolamine 5 mg IV bolus (repeat every 10 minutes) OR
   • Nicardipine/clevidipine infusion OR
   • Nitroglycerin 5 mcg/min IV (titrate up) 1, 5
5. Titrate carefully to achieve gradual blood pressure reduction 1

Special Considerations

• If wide-complex tachycardia develops: Administer sodium bicarbonate 1 mEq/kg IV bolus due to cocaine's sodium channel blocking effects 1, 2
• If hyperthermia present: Initiate rapid external cooling immediately, as this is life-threatening 1, 3
• Monitor continuously for hypotension after cocaine metabolism, as effects may reverse 2
• Consider medical toxicology consultation for severe cases 2

Evidence Quality Context

The 2019 European Society of Cardiology guidelines and 2025 American Heart Association recommendations provide the most current guidance, though all acknowledge that evidence is primarily Level 5 (extrapolated from non-arrest patients and cocaine-naïve volunteers) rather than high-quality randomized trials 5, 1. A 2016 systematic review of 2,358 subjects supports the safety and efficacy of benzodiazepines, with only 8 treatment failures reported 4. No single agent has been proven superior to another, so the treatment approach prioritizes benzodiazepines first, then adds vasodilators based on clinical response 5, 1.