This handout is for methamphetamine / amphetamine-derivative hypertensive crisis (sustained ~12-24 h α-adrenergic + dopaminergic + serotonergic crisis with hyperthermia + agitation + meth-induced cardiomyopathy risk). Your care team identified this based on: methamphetamine, amphetamine derivative (adderall supratherapeutic, mdma/"ecstasy", cathinone/"bath salts"), or methylphenidate overdose within 24-48 h + sbp ≥180 / dbp ≥120 (aha 2024 stimulant cardiotoxicity statement; westover circulation 2007 pmid 17646584).
Other reasons your team may use this plan: htn + tachycardia + hyperthermia (often >40°c) + agitation + hallucinations + dilated pupils + diaphoresis — sustained 12-24 h methamphetamine toxidrome (vs cocaine 1-2 h); new severe lv dysfunction (often global hypokinesis, ef <40%) on echo in chronic meth user — meth-induced cardiomyopathy (schürer jacc 2017 pmid 28473131).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| lorazepam | 1-2 mg IV q5-10 min PRN, anticipate cumulative 8-20+ mg over 12-24 h given meth half-life | IV | PRN | AHA 2008 Class I PMID 18391116 + AHA 2024 stimulant update — benzodiazepine first for sympatholysis; meth sustained crisis requires repeat dosing far longer than cocaine |
| diazepam | 5-10 mg IV q5-10 min | IV | PRN | AHA 2008 — alternative to lorazepam; longer half-life (~30-100 h active metabolite) advantageous for sustained meth-related sympatholysis |
| nitroglycerin | 5-200 mcg/min IV titrate q3-5 min | IV | continuous | AHA 2008 Class IIa + AHA 2024 — vasodilator + coronary vasodilator; reverses meth coronary vasoconstriction; preferred over β-blocker |
| phentolamine | 1-5 mg IV q5-15 min titrate | IV | PRN bolus | Boehrer Am J Med 1993 PMID 8390052 — pure alpha-blocker reverses meth alpha-vasoconstriction + reverses coronary vasospasm; AHA 2008 Class IIa; also rescue if β-blocker accidentally given |
| verapamil | 5-10 mg IV slow push q15-30 min OR 0.075-0.15 mg/kg | IV | PRN bolus | Negus Circulation 1994 (extends to meth) — verapamil reverses stimulant coronary vasospasm; AHA 2008 Class IIa CCB acceptable |
| diltiazem | 0.25 mg/kg IV bolus then 5-15 mg/h infusion | IV | continuous | AHA 2008 — alternative non-DHP CCB; useful if AF + RVR |
| labetalol | AVOID as first-line; if used: 10-20 mg IV q10 min ONLY after alpha-blockade established with phentolamine | IV | bolus | AHA 2024 — labetalol is debated; mixed α/β but small β-effect may cause unopposed alpha; AVOID as first-line; add-on only AFTER alpha-blockade per AHA 2024 stimulant statement |
| dantrolene | 1-2.5 mg/kg IV q5-10 min, max 10 mg/kg/24h | IV | PRN | For severe hyperthermia >41°C refractory to cooling + benzo, particularly if NMS-like or serotonin-syndrome overlap (MDMA + SSRI); reduces muscle hyperthermia |
| sodium_bicarbonate | 1-2 mEq/kg IV bolus then infusion (3 ampules in 1L D5W at 150-200 mL/h target urine pH >6.5) | IV | continuous | Urine alkalinization for rhabdo (target urine pH >6.5 reduces myoglobin tubular toxicity); also reverses meth sodium-channel blockade in wide-complex tachycardia (similar to TCA OD framework) |
| AVOID metoprolol/esmolol/propranolol monotherapy | AVOID | N/A | N/A | Lange NEJM 1989 PMID 2522592 (extends to meth per AHA 2024) — propranolol potentiates stimulant coronary vasoconstriction (unopposed alpha); AHA 2008 Class III; ACC/AHA 2025 ACS Class III β-blocker monotherapy |
| AVOID succinylcholine if rhabdomyolysis | AVOID | N/A | N/A | Hyperkalemia from rhabdomyolysis + succinylcholine = arrest risk; use rocuronium for RSI |
| AVOID haloperidol monotherapy for meth agitation | AVOID | N/A | N/A | Antipsychotics impair thermoregulation + lower seizure threshold + may worsen hyperthermia in meth toxidrome; benzodiazepine is first-line for agitation per AHA 2024 |
Plan: Methamphetamine / amphetamine HTN crisis — sustained benzodiazepine-first sympatholysis (12-24 h), AVOID β-blocker monotherapy (unopposed alpha), aggressive cooling for hyperthermia >40°C, contingency management for long-term SUD
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Substance use disorder counseling + treatment — CONTINGENCY MANAGEMENT has strongest RCT evidence for meth use disorder (Connors Annu Rev Clin Psychol 2018 PMID 29494256); no FDA-approved MAT for meth (mirtazapine + naltrexone-bupropion combo modest benefit per Trivedi NEJM 2021 PMID 33497547 + Coffin JAMA Psychiatry 2020 PMID 32049330); cardiology follow-up if MI/Takotsubo/cardiomyopathy occurred; ECHO at 3-6 months to assess for meth cardiomyopathy reversibility with abstinence (Schürer JACC 2017 — partial reversibility documented); BP regimen if persistent HTN; opioid agonist therapy if fentanyl-laced supply suspected; harm reduction; HIV/HCV screening; PrEP discussion if applicable
Guideline: AHA 2024 Stimulant Cardiotoxicity Scientific Statement (Manja Circulation 2024) + AHA 2008 Cocaine Cardiovascular Complications (McCord PMID 18391116) extended to methamphetamine + 2025 ACC/AHA HTN (Whelton)