cocaine hydrochloride: clinical use

Prescribing considerations

• Restrict administration to clinicians skilled in minimising mucosal absorption and recognising cocaine toxicity.
• Review cardiovascular, neurological, endocrine and medication history before use.
• Avoid application to damaged mucosa or open wounds because systemic absorption may increase.
• Ensure appropriate monitoring, resuscitation equipment and treatment for toxicity are immediately available.
• The selected product is not recommended for children, older people, pregnancy or lactation.

Contraindications and cautions

• Use of cholinesterase inhibitors or hereditary pseudocholinesterase deficiency
• Concomitant adrenaline or other sympathomimetics
• Concomitant guanethidine, reserpine or tricyclic antidepressants
• Epilepsy
• Avoid in porphyria

Monitoring

• Observe during and after administration for agitation, tremor, seizures or altered consciousness.
• Monitor for tachycardia, hypertension, arrhythmia, chest pain and impaired tissue perfusion.
• Monitor respiratory status and temperature where clinically appropriate.
• Use particular caution with hypertension, cardiovascular disease, thyrotoxicosis or diabetes.

Clinical pharmacology

Cocaine produces local anaesthesia through voltage-gated sodium-channel blockade. Inhibition of noradrenaline and dopamine reuptake produces sympathomimetic and central stimulant effects. Mucosal vasoconstriction delays, but does not prevent, systemic absorption; metabolism is predominantly by serum and hepatic pseudocholinesterase.

Formulation and product differences

• The selected product is a sterile oromucosal solution and nasal spray solution supplied with a pump actuator.
• It contains dilute hydrochloric acid and water for injections and has no preservative.
• It is intended for topical, single-patient use and is not suitable for injection or ingestion.
• It is incompatible with phenol, sodium borate and silver nitrate.