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Scottish Palliative Care Guidelines print pdf

Lidocaine


Introduction

Lidocaine Plaster in Palliative Care

 Description

  • Lidocaine is a local anaesthetic effective in some types of neuropathic pain such as post-herpetic neuralgia.
  • It is available in a topical plaster formulation, with approximately 3% systemic absorption, reducing the risk of systemic adverse reactions and drug interactions.
  • The use of lidocaine plasters in palliative care has not been investigated extensively and is outside marketing authorisation.  It is non-Formulary in some NHS Boards.

Preparations

Versatis ®

Medicated plaster (10x14cm) containing 700mg (5% w/w) of lidocaine.

Indications

A palliative care specialist may recommend lidocaine plasters for:

  • localised neuropathic pain (particularly associated with allodynia) that is unresponsive to opioids and adjuvant analgesics.
  • locally painful bone metastases unresponsive to standard treatments (paracetamol, opioids, adjuvant analgesics, radiotherapy) or when standard treatments are inappropriate, poorly tolerated or contraindicated.
  • short term treatment of localised, severe uncontrolled bone or neuropathic pain, while adjuvant analgesics are being titrated.

Cautions

Cautions

  • Do not apply the plaster to inflamed, broken or infected skin or to wounds.
  • Use with caution in patients with severe cardiac disease; elimination may be delayed in patients with severe renal or liver impairment.

Drug interactions

  • Use with caution in patients receiving a Class I anti-arrhythmic drug (eg flecainide).

Side effects

  • Application site reactions including erythema, rash and pruritis are common.
  • Systemic allergic reactions have been reported but are very rare.

Dose and Administration

Starting a lidocaine plaster

  • Remove any hairs with scissors; do not shave the area.
  • Plasters can be cut to size before the backing is removed without affecting drug delivery.
  • Apply one plaster directly over the painful area for up to 12 hours in each 24 hour period. The plaster free interval may reduce the risk of skin reactions.  However some patients may benefit from the patch being applied for 24 hours.
  • The plaster site should be specified on the prescription chart and on the monitoring sheet.
  • A new plaster is applied every 24 hours.

 Titration

  • The dose is titrated to give adequate analgesia (up to a maximum of three plasters) depending on the number and size of the painful site or sites. After initiation of treatment review after 48 hours and document on monitoring sheet.
  • Monitor the patient’s pain and other analgesics; these may need to be reduced if the pain responds well to lidocaine.
  • A used plaster should be folded over and can then be put in the sharps bin or household waste.

Practice Points

Pain Assessment

  • A 0-10 pain scale should be used to assess the patient’s pain now and over the past 24 hours.
  • Record the pain scores on the monitoring sheet before the plaster is applied and after 48 hours.

Review of lidocaine plaster

  • Most patients will respond within 2 weeks; discontinue the plaster if no benefit.
  • It is often possible to discontinue the plaster without the pain recurring as the local effect on nerve endings persists after the plaster is removed.
  • If the pain responds, try a plaster free period after 7 days of plaster use.
  • remove the lidocaine plaster(s) for 24 hours and assess the patient.
  • If the pain returns or worsens; restart the lidocaine plaster.
  • If the patient remains pain free or with stable pain; discontinue the lidocaine plaster.
  • Continued treatment - reassess with a further plaster free trial on a monthly basis to determine whether the number of plasters needed to cover the painful area can be reduced, or if the plaster-free period can be extended.

Monitoring

  • A monitoring sheet  is recommended for each patient started on a lidocaine plaster.
  • If a lidocaine plaster is being used for more than one pain site, a separate monitoring sheet should be completed for each site.
  • The monitoring sheet should be updated each time the patient is assessed.
  • Check the skin site – if a local reaction occurs, the plaster may need to be stopped.

Resources

Twyross R et al.  Palliative Care Formulary (Fourth Edition).  Palliativedrugs.com.  Nottingham, 2011

Electronic Medicines Compendium, Grunenthal Ltd.  Lidocaine patches 5% (Versatis®).  Summary of  product characteristics.  Updated January 2012.  www.medicines.org.uk.

References