How are hypertension and tachycardia managed in methamphetamine toxicity?

Updated: Aug 15, 2018
  • Author: John R Richards, MD, FAAEM; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Answer

If sedation fails to reduce blood pressure, antihypertensive agents such as beta-blockers and vasodilators are effective in reversing methamphetamine-induced hypertension and tachycardia.

With regard to choice of beta-blockers, labetalol is preferred because of combined anti–alpha-adrenergic and anti–beta-adrenergic effects. Labetalol has been shown to safely lower mean arterial pressure in cocaine-positive patients. [79] Carvedilol, which like labetalol is a nonselective beta-blocker with alpha-blocking activity, may also be effective for this indication. [80, 81] Esmolol is advantageous because of its short half-life but must be administered via IV drip. Metoprolol has excellent CNS penetration characteristics and may also ameliorate agitation, as previously mentioned.

These drugs should be given IV in smaller than usual doses and titrated to effect. The concern for "unopposed alpha stimulation," with sudden rise in blood pressure or coronary artery vasoaspasm after beta-blocker therapy, is theoretical and has never been demonstrated in patients with methamphetamine toxicity. [67] An extensive evidence-based systematic review of this topic demonstrated the safety and efficacy of beta-blockers for this indication. [67] At our institution, we routinely use beta-blockers for methamphetamine-induced tachycardia and hypertension with good results.

In rare instances, afterload reduction with agents such as hydralazine, nitroprusside, or fenoldopam may be necessary. [67]


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