When should epinephrine be used with great caution?

In patients with hypertension, ischemic heart disease, peripheral vascular occlusive disease, hyperthyroidism, or pheochromocytoma, epinephrine should either be avoided or diluted, and the patient must be carefully monitored. Epinephrine should either be avoided or diluted in patients taking beta-blocking drugs, especially propranolol, as they are at risk for developing paradoxical hypertension, reflex bradycardia, and cardiac arrest. Epinephrine is contraindicated in patients taking phenothiazines, tricyclic antidepressants, and monoamine oxidase (MAO) inhibitors. Epinephrine should also be avoided in pregnancy, especially during the first and third trimesters, and in patients with a history of psychiatric disease. Many authors also suggest avoiding epinephrine for the digits, especially if the patient is a heavy smoker or has peripheral arteriosclerosis, vasospastic disease, collagen vascular disease, or other peripheral vascular disease.