Systemic Lidocaine for Pain Management

Overview: 

Introduction

Lidocaine is a local anesthetic that also has systemic analgesic effects. Systemic lidocaine is increasingly used off-label for the treatment of various pain conditions. 

 

Mechanism of Action

Potential mechanisms of analgesic action are: 

  • Anti-inflammatory effects (most important mechanism)
  • Inhibition of spontaneous impulse generation from injured peripheral nerves 
  • Suppression of polysynaptic reflexes in the spinal dorsal horn 
  • The analgesic effects are mediated through action on voltage-gated ion channels, including sodium, potassium, and calcium channels, and ligand-gated channels, including N-methyl-d-aspartic acid (NMDA) receptors, in the central nervous system
  • Additionally, lidocaine targets G-protein-coupled receptors 
Clinical Use: 
  • Continuous infusions reduce surgical as well as nonsurgical acute pain such as renal colic, critical limb ischemia, acute migraine, and radicular lower back pain. 
  • Short lidocaine infusions can achieve longer lasting symptom reduction in chronic pain conditions such as neuropathic pain and cancer pain
  • Lidocaine has been shown to be a gastrointestinal pro-peristaltic drug 
  • A preventive analgesic effect has been suggested

 

Indications

  • Analgesia following surgery
  • Renal colic
  • Critical limb ischemia
  • Acute migraine
  • Radicular lower back pain
  • Herpetic neuropathy 
  • Complex Regional Pain Syndrome
  • Fibromyalgia
  • Chronic Neuropathic Pain
  • Refractory Cancer Pain
Special Considerations: 

Contraindications

  • Sensitivity or allergy to local anesthetics
  • Concurrent use of regional anesthesia (peripheral nerve infusions, nerve   blocks, epidural anesthesia, Exparel (liposomal bupivacaine), oral lidocaine (mexilitine), or single shot regional technique in the last 4-8 hours. 
  • Cardiac conduction abnormalities (Adams-Stokes syndrome, Wolff-Parkinson-White (WPW) syndrome, 2nd or 3rd degree heart blocks (unless patient has a pacemaker) or other dysrhythmia
  • Severe heart failure (ejection fraction less than 20%),          
  • Severe hepatic (bilirubin greater than 1.46 mg/dl) 
  • Renal impairment (GFR less than 30 ml/min or ESRD)
  • Seizure disorder 
  • Acute porphyria
References: 

Eipe, N et al. Intravenous lidocaine for acute pain: an evidence-based clinical update. BJA Education 2016 Volume 16, Issue 9, 292 - 298

De Oliveira, K., Eipe, N. Intravenous Lidocaine for Acute Pain: A Single-Institution Retrospective Study. Drugs - Real World Outcomes 7, 205–212 (2020)

Challapalli V, et al. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003345. 

Lee JT, et al. Lidocaine for Cancer Pain in Adults: A Systematic Review and Meta-Analysis. J Palliat Med. 2019 Mar;22(3):326-334.

Author: 
Marilyn A Bazinski
Matthias Behrends