HelixTalk Episode #118 - Cocaine and Beta-blockers: Absolute Contraindication or Medical Myth?

Date posted: September 8, 2020, 6:00 am

In this episode, we discuss the proposed risks of using beta blockers in patients with cocaine use disorders and whether evidence supports this drug interaction as an “absolute” contraindication.

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Key Concepts

1. Cocaine causes vasoconstriction via the alpha-1 receptor.  Normally some of this vasoconstriction is offset by the beta-2 receptor, which causes opposing vasodilation.  There is a theoretical concern that combining cocaine with beta blockers could lead to “unopposed alpha” activation and profound hypertension.
2. There is very little data supporting the “unopposed alpha” theory.  Of the data available, most implicates propranolol but not other beta blockers as potentially being harmful when used with cocaine.
3. Larger, retrospective studies and meta-analyses suggest that there are no harmful effects of using beta blockers in patients with cocaine use disorders, especially in patients with cocaine-associated chest pain or those with heart failure with reduced ejection fraction.
4. While this topic is still controversial, the best available evidence suggests this theoretical interaction is a medical myth and should not lead to withholding beta blocker therapy in patients with clear indications.

References

• Richards JR, Hollander JE, Ramoska EA, et al. β-Blockers, Cocaine, and the Unopposed α-Stimulation Phenomenon. J Cardiovasc Pharmacol Ther. 2017;22(3):239-249. doi:10.1177/1074248416681644
• Pham D, Addison D, Kayani W, et al. Outcomes of beta blocker use in cocaine-associated chest pain: a meta-analysis. Emerg Med J. 2018;35(9):559-563. doi:10.1136/emermed-2017-207065
• Mann BK, Bhandohal JS, Saeed M, Pekler G. Beta Blocker Therapy in Heart Failure Patients with Active Cocaine Use: A Systematic Review. Cardiol Res Pract. 2020;2020:1985379. Published 2020 May 8. doi:10.1155/2020/1985379