Cocaine Contraindications and Precautions
- breast-feeding
- accidental exposure
- acute myocardial infarction
- cardiac arrhythmias
- cardiac disease
- cerebrovascular disease
- children
- coronary artery disease
- elderly
- hepatic disease
- hypertension
- infants
- infection
- myocardial infarction
- nasal septal perforation
- nasal trauma
- neonates
- neoplastic disease
- ocular exposure
- ophthalmic administration
- parenteral administration
- pregnancy
- pseudocholinesterase deficiency
- seizure disorder
- seizures
- substance abuse
- thyrotoxicosis
- Tourette’s syndrome
Cocaine Contraindications and Precautions
Use cocaine with extreme caution if inflammation is present at the site of application. Cocaine topical solutions should be used with extreme caution in patients with severely traumatized mucosa (e.g., nasal trauma) and infection in the region of intended application. Prolonged intranasal use of cocaine can cause ischemic mucosal damage or nasal septal perforation. Topical solutions of cocaine intended for use in anesthetizing the mucous membranes of the oral, laryngeal, and nasal cavities are NOT intended for systemic parenteral administration or ophthalmic administration. Cocaine use is contraindicated in patients with known hypersensitivity to the drug.
Because cocaine is readily absorbed from mucous membranes and can cause severe adverse effects, the drug should be used with caution and careful attention should be given to dosage and administrative technique. Avoid unintended ocular exposure or accidental exposure to the mucus membranes. Resuscitative drugs and equipment for the treatment of severe adverse reactions should be readily available any time cocaine is used.
Because of the significant sympathomimetic response generated by cocaine, its use is relatively contraindicated in patients with cardiac disease, an acute myocardial infarction, significant risk factors for coronary artery disease, a history of cardiac arrhythmias, uncontrolled hypertension, seizure disorder or seizures, thyrotoxicosis, Tourette’s syndrome, or cerebrovascular disease.
Use cocaine with extreme caution in acutely ill, debilitated, or elderly patients. The elderly may be more sensitive to sympathetic stimulation than are young adults. Elderly males have reduced plasma cholinesterase activity which may result in a reduced ability to metabolize cocaine. A reduced dosage regimen is recommended for elderly patients.
Use cocaine with caution in patients with decreased cholinesterase activity, as the risk of cocaine-induced side effects may be more likely in those patients with a reduced capacity for cocaine biotransformation. The metabolism of cocaine is usually rapid bur may be decreased in patients with low levels of cholinesterase activity in the liver or the plasma. Such patients may include those patients receiving systemic cholinesterase inhibitor treatments (see Drug Interactions), patients with neoplastic disease, patients with hepatic disease, or patients with pseudocholinesterase deficiency.
Because of cocaine’s toxicity, the drug is not recommended for use in children and infants under 6 years of age. For children aged 6 years and older, it is recommended that cocaine be used with caution and in reduced dosage. Neonates are especially at risk for cocaine-induced adverse events due to low endogenous levels of cholinesterase activity and a reduced capacity to inactivate the drug. Care should be taken in topical administration to avoid unintended exposure to mucus membranes that might result in significant absorption and an increased risk of side effects in children and infants.
Animal reproduction studies with cocaine have not been done, and the effects of the drug’s use on the human fetus and fertility are not known. In medical use, cocaine is classified as FDA pregnancy risk category C and should only be used during pregnancy when clearly needed. Cocaine use/abuse can lead to major toxicity in the mother, fetus, and neonate. Cocaine abuse by a pregnant woman may be considered teratogenic. Cocaine causes placental vasoconstriction, decreasing the blood flow to the fetus, and may cause an increase in uterine contractility. Women who use cocaine during pregnancy are at significant risk for shorter gestation, premature delivery, spontaneous abortion, abruptio placentae, and death. Maternal illicit use of cocaine during pregnancy has been epidemiologically associated with developmental delay in cocaine-exposed infants.
Cocaine is excreted in breast milk and may have adverse effects on nursing infants. The American Association of Pediatrics considers cocaine to be contraindicated during breast-feeding. Benzoylecgonine can be detected in breast milk for up to 36 hours after the mother’s last dose of cocaine. Cocaine and its metabolite have been found in an infant’s urine after breast-feeding. Those exposed to cocaine through breast milk may develop symptoms of cocaine toxicity (i.e. irritability, tremulousness, increased startle response). Because of the potential for serious adverse effects in the nursing infant, it is recommended that nursing be discontinued during cocaine use. Temporary cessation of breast-feeding is recommended when medical use is unavoidable.
Cocaine is a strong CNS stimulant and is therefore subject to substance abuse and psychological dependence (i.e. drug addiction) or criminal diversion. Repeated topical application of cocaine can result in psychological dependance and tolerance; this drug is often abused by parenteral or intranasal administration or by inhalation (smoking). Drug addiction is characterized by compulsive use, use for non-medical purposes, and continued use despite harm or risk for harm. Patients with a previous history of substance abuse may be at increased risk of relapse if treated with cocaine.
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