Drugs List

Therapeutic Indications

Uses

Local anaesthetic for dental infiltration anaesthesia
Local anaesthetic for dental nerve block

Dosage

Due to the complexity and specialist nature of using anaesthesia, specific dosing information on this agent is not included. When using this agent, specialist literature, national guidelines and Trust policies should be consulted to ensure appropriate dosage and assessment of all relevant patient factors.

Administration

For dental injection via infiltration or nerve block.

Contraindications

Atrioventricular block
Hypertension
Severe myocardial depression
Valvular heart disease

Precautions and Warnings

Children under 18 years
Bradycardia
Breastfeeding
Cardiac arrhythmias
Cerebrovascular insufficiency
Epileptic disorder
Hepatic impairment
Hypovolaemia
Ischaemic heart disease
Peripheral vascular disease
Porphyria
Pregnancy
Respiratory impairment
Severe renal impairment
Thyrotoxicosis

Treatment to be initiated and supervised by a specialist
Aspirate prior to injection to avoid intravascular administration
Avoid local anaesthetics if inflammation in region of proposed injection
Do NOT inject into the extremities or penis
Do not inject near site of skin infection
Resuscitation facilities must be immediately available
Monitor vital signs, respiration & cardiac function
Anaesthetic effect may impair swallowing
In obese patients dosing should be based on ideal weight

Pregnancy and Lactation

Pregnancy

Use lidocaine with adrenaline with caution in pregnancy.

No adequate and controlled studies for the combined product have been carried out in pregnant women. For the combined product, animal reproduction studies revealed no evidence of foetal harm after doses greater than 6 times the human dose were administered. Animal studies are not always predictive of human response.

Lidocaine is widely used as a anaesthetic during pregnancy (e.g. given as a epidural during labour). It is the one of the antiarrhythmic drugs of choice during pregnancy (Schaefer 2007). Lidocaine rapidly crosses the placenta to the foetus, appearing in foetal circulation within a few minutes of administration to the mother. However both the foetus and neonate are capable of metabolising lidocaine. Schaefer comments that there is no recognisable teratogenic effects in human pregnancies. In prospective studies of more than 1200 pregnant women, there were no major increases in major or minor anomalies when lidocaine was used. However when used as an epidural anaesthetic severe adverse effects in the foetus has been observed, albeit rarely, including transient alternations to cardiopulmonary adaptation, alterations in brain-stem evoked potential and possible loss of thermoregulatory. Lidocaine used during labour may produce central nervous system depression in the newborn with high serum levels.

Schaefer comments that the coadministration of adrenaline with local anaesthetics during pregnancy to limit vascular absorption is acceptable, as it reduces absorption into the blood.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use lidocaine with adrenaline with caution in breastfeeding.

A very low amount of lidocaine is excreted into human milk (even in intravenous treatment of cardiac arrhythmia), however the bioavailability of lidocaine is very poor. The manufacturers state that due to the small quantity of drug used during dental anaesthesia that would result in a minor exposure to the infant, lidocaine may be used in breastfeeding at the request of the patient. Information on LactMed states that lidocaine is not expected to cause any adverse effect in breastfed infants and thus no special precautions are required. Schaefer concludes that for dental treatment, local anaesthesia (included combinations with adrenaline) may be used in breastfeeding. Low dose epidural, topical, inhaled or ophthalmic adrenaline are unlikely to interfere with breastfeeding.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Agitation
Allergic reaction
Anaphylactoid reaction
Apprehension
Arrhythmia (including ventricular tachycardia and atrial fibrillation)
AV conduction disorders
Blurred vision
Bradycardia
Cardiac arrest
Cardiovascular collapse
Cardiovascular effects
Changes in pulse
Confusion
Convulsions
Cutaneous lesions
Dizziness
Double vision
Drowsiness
Euphoria
Excitation
Headache
Hypotension
Hypoxia
Light-headedness
Malaise
Methaemoglobinaemia
Myocardial depression
Nausea
Nervousness
Numbness
Nystagmus
Oedema
Palpitations
Rash
Respiratory arrest
Respiratory depression
Sensation of cold
Sensation of heat
Sweating
Tachycardia
Tinnitus
Tremor
Twitching
Unconsciousness
Urticaria
Vasovagal attacks
Vomiting

Presentation

Solution for injection containing lidocaine hydrochloride and adrenaline tartrate

Drugs List

Therapeutic Indications

Uses

Local anaesthetic for dental infiltration anaesthesia
Local anaesthetic for dental nerve block

Dosage

Due to the complexity and specialist nature of using anaesthesia, specific dosing information on this agent is not included. When using this agent, specialist literature, national guidelines and Trust policies should be consulted to ensure appropriate dosage and assessment of all relevant patient factors.

Administration

For dental injection via infiltration or nerve block.

Contraindications

Atrioventricular block
Hypertension
Severe myocardial depression
Valvular heart disease

Precautions and Warnings

Children under 18 years
Bradycardia
Breastfeeding
Cardiac arrhythmias
Cerebrovascular insufficiency
Epileptic disorder
Hepatic impairment
Hypovolaemia
Ischaemic heart disease
Peripheral vascular disease
Porphyria
Pregnancy
Respiratory impairment
Severe renal impairment
Thyrotoxicosis

Treatment to be initiated and supervised by a specialist
Aspirate prior to injection to avoid intravascular administration
Avoid local anaesthetics if inflammation in region of proposed injection
Do NOT inject into the extremities or penis
Do not inject near site of skin infection
Resuscitation facilities must be immediately available
Monitor vital signs, respiration & cardiac function
Anaesthetic effect may impair swallowing
In obese patients dosing should be based on ideal weight

Pregnancy and Lactation

Pregnancy

Use lidocaine with adrenaline with caution in pregnancy.

No adequate and controlled studies for the combined product have been carried out in pregnant women. For the combined product, animal reproduction studies revealed no evidence of foetal harm after doses greater than 6 times the human dose were administered. Animal studies are not always predictive of human response.

Lidocaine is widely used as a anaesthetic during pregnancy (e.g. given as a epidural during labour). It is the one of the antiarrhythmic drugs of choice during pregnancy (Schaefer 2007). Lidocaine rapidly crosses the placenta to the foetus, appearing in foetal circulation within a few minutes of administration to the mother. However both the foetus and neonate are capable of metabolising lidocaine. Schaefer comments that there is no recognisable teratogenic effects in human pregnancies. In prospective studies of more than 1200 pregnant women, there were no major increases in major or minor anomalies when lidocaine was used. However when used as an epidural anaesthetic severe adverse effects in the foetus has been observed, albeit rarely, including transient alternations to cardiopulmonary adaptation, alterations in brain-stem evoked potential and possible loss of thermoregulatory. Lidocaine used during labour may produce central nervous system depression in the newborn with high serum levels.

Schaefer comments that the coadministration of adrenaline with local anaesthetics during pregnancy to limit vascular absorption is acceptable, as it reduces absorption into the blood.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use lidocaine with adrenaline with caution in breastfeeding.

A very low amount of lidocaine is excreted into human milk (even in intravenous treatment of cardiac arrhythmia), however the bioavailability of lidocaine is very poor. The manufacturers state that due to the small quantity of drug used during dental anaesthesia that would result in a minor exposure to the infant, lidocaine may be used in breastfeeding at the request of the patient. Information on LactMed states that lidocaine is not expected to cause any adverse effect in breastfed infants and thus no special precautions are required. Schaefer concludes that for dental treatment, local anaesthesia (included combinations with adrenaline) may be used in breastfeeding. Low dose epidural, topical, inhaled or ophthalmic adrenaline are unlikely to interfere with breastfeeding.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Agitation
Allergic reaction
Anaphylactoid reaction
Apprehension
Arrhythmia (including ventricular tachycardia and atrial fibrillation)
AV conduction disorders
Blurred vision
Bradycardia
Cardiac arrest
Cardiovascular collapse
Cardiovascular effects
Changes in pulse
Confusion
Convulsions
Cutaneous lesions
Dizziness
Double vision
Drowsiness
Euphoria
Excitation
Headache
Hypotension
Hypoxia
Light-headedness
Malaise
Methaemoglobinaemia
Myocardial depression
Nausea
Nervousness
Numbness
Nystagmus
Oedema
Palpitations
Rash
Respiratory arrest
Respiratory depression
Sensation of cold
Sensation of heat
Sweating
Tachycardia
Tinnitus
Tremor
Twitching
Unconsciousness
Urticaria
Vasovagal attacks
Vomiting

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Further Information

Last Full Review Date: February 2014

Reference Sources

Acute Porphyria Safe List, Welsh Medicines Information Centre, Cardiff and Vale NHS Trust, September 2013.

Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 2nd edition (2007) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

European Porphyria Initiative, Available at; https://www.porphyria-europe.com/index.asp
Last revised: November 21, 2008 Last accessed: February 12, 2014

Joint Formulary Committee. British National Formulary. 66th ed. London: BMJ Group and Pharmaceutical Press; 2013. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press https://www.medicinescomplete.com [Accessed on 12, February 2014].

Medications and Mothers' Milk, 14th Edition (2010) Hale, T. Hale Publishing, Amarillo, Texas.

Paediatric Formulary Committee. BNF for Children 2013-2014. London: BMJ Group, Pharmaceutical Press, and RCPCH Publications; 2013. Paediatric Formulary Committee. BNF for Children (online) London: BMJ Group, Pharmaceutical Press, and RCPCH Publications https://www.medicinescomplete.com [Accessed on 12, February 2014].

Summary of Product Characteristics: Lignospan Special. Septodont Ltd. Revised August 2013.

N.A.P.O.S The Drug Database for Acute Porphyria, available at; https://www.drugs-porphyria.com/languages/UnitedKingdom/s1.php?l=gbr
Last revised: September 9, 2011 Last accessed: February 12, 2014

UK medicines Information (UKMi) pharmacists for NHS healthcare professionals Q&A 152.3: What is the clinical significance of potential drug interactions with local anaesthetic preparations used in primary care dentistry? Issue date June 2013. Available at: https://www.ukmi.nhs.uk/activities/medicinesQAs/default.asp
Last accessed: February 12, 2014

UK medicines Information (UKMi) pharmacists for NHS healthcare professionals Q&A 153: Allergy to local anaesthetic agents used in density - what are the signs, symptoms, alternative diagnosis and management options? Issue date July 2012
Available at: https://www.ukmi.nhs.uk/activities/medicinesQAs/default.asp
Last accessed: February 12, 2014

US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Epinephrine. Last revised: September 7, 2013
Lidocaine. Last revised: September 7, 2013
Last accessed: February 12, 2014