Mast Cell Disorders Forum - Local Anesthetics

Doozlygirl

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Local Anesthetics
09/08/12 at 19:02:51

I've been reading up on local anesthetics and have found some interesting information I'd like to share.

TMS and Mastokids resources cite that mast cell patients should AVOID the ESTER group of local anesthetics, which includes procaine (novacaine), chloroprocaine, tretracaine, and benzocaine. I have learned that reactions to these meds are likely due to issues with a breakdown molecule of these meds, called PABA.

TMS, Mastopedia and Mastokids resources cite that AMIDE group local anesthetics are recommended for mast cell patients, and include lidocaine (brand Xylocaine); Mepivacaine (brand Carbocaine); Bupivicaine (brand Sensorcaine and Marcaine) and prilocaine (brand Citanest Dental).

TMS, Mastopedia and Mastokids lists include methylparaben and metabisulfites as degranulators.

Epinephrine is often included to keep the local anesthetic localized longer and not move or limit bleeding.

I have pulled the monographs of available amide anesthetics and through charting the ingredients noticed several trends:

1. Formulations in a multi dose vials include methylparabens.
2. Formulations with epinepherine include metabisulfites.
3. Every forumlation includes sodium chloride and sodium hydroxide
and/or hydrochlric acid to adjust the pH.
4. The cleanest formulations include only active ingredient.
5. Each one offers a MPF version = Methylparabens Free

Of the 18 formulations of amide local anesthetics, I found five offered in single dose vials without known mast cell degranulators as inactive ingredients:
1. Lidocaine MPF (brand Xylocaine MPF)
2. Mepivacaine MPF (brand Carbocaine MPF)
3 and 4. Bupivacaine MPF (brand Sensorcaine MPF and Marcaine MPF)
5. Prilocaine (brand Citanest Dental).

If possible, ask your physician if one of these formulations would work for any upcoming dental work, biopsies, or other procedures. I believe that appropriate medication choice may limit unnecessary episodes of degranulation.

Lyn

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« Last Edit: 09/09/12 at 07:07:34 by Doozlygirl »

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Anaphylaxing

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Re: Local Anesthetics
Reply #1 - 09/08/12 at 22:20:09

Wow great info Lyn thanks so much!!

as an aside, was making headway on which meds preservative free at the hospital for surgery, but they constantly change what the carry based on cost and it seems nearly impossible to ensure certain ones are there at any time AHK! All the extra details for us.

I was planning to go for lidocaine without epi for the incisions, but sounds like there'll be some parabens in it. Ugh

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Doozlygirl

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Re: Local Anesthetics
Reply #2 - 09/09/12 at 05:57:15

Ana,
I got on this path when figuring out what to use for my dental work, then decided to follow through (which is rare for me therse days to actually feel like I can accomplish anything!?!

).

I guess I should call each of these versions (lido, lido w/Epi, lido MPF, lido MPF w/Epi) and not formulations. Since the formulation would likely best describe what you are talking about --ingredient differences between brand and generics then again the differences between generics manufacuturers.

I purposely looked up the monographs, and not individual products, as I know the product offered will change based on cheapest price du jour. The mongraphs set the FDA approved language for the class of drugs. I just wanted to find out the version I could possibly tolerate. And I did!! From this point forward I will request for a MPF, epi-free AMIDE local. . They can decide which amide they want to use, as I understand there are inherient benefits to each of them, although they are somewhat interchangable.

In my case I have elevated heparin during degranulation, so it doesn't make sense to add to my degranulation load with the metabisulfites in the epi. When the epi could limit the bleeding. Chicken and egg thing here! And the parabens can make even healthy individuals react,so they are out.

I am so sick of having all this be unknown --NOT knowing what I react to. And while I give in to the fact that mast cell reactions CAN be random, I am doing what I do best - wade through mounds of obscure data and find a light at the end of the tunnel to guide me to the next thing. If I can eliminate the pool of known degranulators, then I have a better shot of NOT reacting to what's left.

Take care,
Lyn

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Joan

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Re: Local Anesthetics
Reply #3 - 09/09/12 at 15:27:15

I have reached the point where I want nothing given by IV that has any preservatives or additives at all. I had a severe breathing issue twice from IV Benadryl (which was probably preserved) vs. an injected version that didn't have any preservative.

Ana, can you ask the hospital to order additive-free meds for your surgery? I don't even know if we can ask for that in the U.S.

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Re: Local Anesthetics
Reply #4 - 09/09/12 at 21:13:04

Yes I'm trying to Joan but I'm not sure how far I'll get.

I agree everything I've ever had IV has caused issues and of course a lot of IV meds come with surgery! Even saline which I suspect had preservatives also.

My hospital does carry some that just have additives to adjust pH but no preservatives, but their stock keeps changing so it's going to be a mega hassle. I've had to contact the manufacturer for every medication and am going over with anesthesia in advance to try and sort it out but I don't know yet how accommodating they will be.

Also that's all helpful if you stay within the expected course but if you encounter glitches or instability they'll likely need to use off list meds urgently and not be able to check for additives.

Too many details for us aren't there? Yeesh.

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Daffodil

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Re: Local Anesthetics
Reply #5 - 09/09/12 at 23:39:58

Thank you Lyn for sharing the information on local anesthetics with us.
I really need to go to the dentist but just cannot face it as I just did not know where to start explaining my condition but armed with this info I feel much more confident about going.

I was given Epinephrine once and my blood pressure went sky high so that must have been because of the metabisulfites in it. I have epi pens so this has prompted me to get them changed if I can.

Thanks again for this post.

Anne

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Doozlygirl

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Re: Local Anesthetics
Reply #6 - 09/10/12 at 06:31:59

Anne and Ana,
I've read that the sulfites in the lido/other local with epinepherine is used to prevent oxidation and extend the shelf life of the med. All intrathecal and epidural injections (in the spinal column) used during anethesia MUST be given preservative free (sulfites and methylparabens free). This tells me that hospital pharmacy stock must carry various types of preservative free. Of course this may be different in the dental office.

If my surgeon/anesthesiologist wants to use the amide AND epi, all they have to do is draw up the meds from separate preservative free vials. They can do this bedside. The preservatives in each case are used to prolong shelf-life, not to enhance your anesthesia experience at all.

And now back to the epi-pen and sulfites. I've read numerous posts and websites, and everyone, including Dr Castells warns that if epi is warranted, then use epi-pen even if you have a sulfite intolerance. I suppose there are several reasons for this. There is no sulfite-free readily injectable epi source with a long shelf life. From what I can find online, sulfite free epi comes in vials, which would mean you'd have to have a needle to draw up the epi, then inject it. Way too much messing around. If you consider the bucket theory, then eliminiating the preservatives from other meds will keep the level lower in the bucket.

I'd love to hear if others know differently.

Lyn

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« Last Edit: 09/10/12 at 19:35:01 by Doozlygirl »

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Doozlygirl

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Re: Local Anesthetics
Reply #7 - 09/10/12 at 07:14:55

Joan,
In the US you can make arrangements that only preservative free IV medications be administered, but I'm sure there will be a caveat that preservatives will be given if medically warrented/no preservative free med is available. While there are these locked medication dispensing units on the nursing floors now, they only offer limited med choices. So, it may take longer to get a preservative free med from the inpatient pharmacy. You may want to have these preservatives integrated into your medical records allergy list and then again in the pharmacy dispensing system.

Ana,
Have you thought about having methylparabens, metabisulfites AND the generic term preservatives added to your allergies list in your medical records and crossed over into the pharmacy dispensing program? I don't know what the candian health system uses for medical records, but in the US, there is a better shot of havng those contraindicated meds flagged by doing this. The down fall would be it woudl necessitate an override if there were no preservative free meds available.

In the US, Cerner Multim is a database commonly used to provide content on medication interactions, ingredients and allergy lists used to fuel many pharmacy dispensing programs and link with medical records systems. Find out from your hospital pharmacy department if they use one of these databases, or one of the others. I've accessed Cerner Multim on my hospital website and I often pull up Cerner Multim entries on sites like drugs.com.

Beware, these programs likely only mention ingredients and not their function, so you may want to mention both --specific ingredients and the term 'preservatives'. It is these outsourced computer databases that provide the crossover language, in the form of lists. I've worked with the Cerner folks in the past on getting the verbiage and ingredients correct regarding contrast media.

Lyn

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Anaphylaxing

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Re: Local Anesthetics
Reply #8 - 09/10/12 at 08:02:00

Thanks Lyn

We're not all electronic here yet. And I spoke with the pharmacy manager who seemed to have no clue how to access where the additives were listed, so likely wouldn't be flagged in that hospital unfortunately. Glad there's progress in US. Trying to sort out in advance

That's a good idea to add it to the allergy list

Here, I've aways seen Xylocaine with and without Epi and with and without preservative in plastic rectangles. I'm wondering, if it says without preservative does that include the methyparaben? I hadn't even gone into this yet with pharmacy as I knew they had Xylo without epi without preservative in the OR and presumed that would be safe

Would be interested to know what you think

As an aside--Epi's action is to increase BP so this wouldn't necessarily have been the preservative for the case above. I was given too much of the preservative free stuff and it caused so much peripheral constriction that I had a heart attack. I was not hypotensive when it was given and in retrospect they generally caution not to use Epi unless desperate airway obstruction unless the patient is hypotensive due to the risk of MI and stroke. Though sounds as though each doc is different on that as there were various opinions last time it came up.

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Doozlygirl

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Re: Local Anesthetics
Reply #9 - 09/10/12 at 08:50:59

Ana,
That is the $10M question. When you ask for 'preservative free', what exactly does that mean? My best guess, is that it means different things to different people, depending upon training.

I guess that if a nurse knew you needed preservative free, they are familiar with the MPF version in a single dose vial. But what about the sulfites? They would HAVE to know that an amide with epi always comes with sulfites, since there is no such thing as amide + epi - sulfites.

I presume that pharmacists would be familiar with MPF and sulfite free. Would they catch BOTH if the script read "preservative free?" I had that same question last night as I was looking for online chatter on the same topic. I'd be interested to hear what your pharmacy says.

I also bet that in general most physicians don't have a perspective on preservative free, unless they have personally used MPF or sulfite-free versions during procedures.

And at what point does our request for preservative free meds trigger the medical staff to think we are nuts? I can see that value in mentioning "previous known reactions" and getting that in the medical record.

Oh, I recall the days of paper medical records and orders in triplicate on carbon paper. Those were much simplier times, compared to now. Now decisions that have been made behind the scenes dictate medicine in the US. I hope your canadian health system is open to learning from the mistakes made in the US before embarking on going paperless.

Lyn

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Joan

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Re: Local Anesthetics
Reply #10 - 09/10/12 at 17:48:36

The problem is, in myself and others, that epi brings down BP during a degranulation. Epipens in the U.S. are clearly marked to contain sulfites, but they also say that in an emergency that they should be used anyway. I would say that each person should follow the instructions of his/her doctor on that. This is probably one of those things that is very individual.

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Joan

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Anaphylaxing Guru Offline Hang in there! You can do it! Posts: 836	Re: Local Anesthetics Reply #11 - 09/10/12 at 19:43:39 Agreed seems to be a number of ppl with similar experiences with that BP issue like I think came up before. I still carry Epipens, but am mulling over carrying preservative free syringes to draw up instead, but haven't quite had the energy to sort that out yet. Fingers crossed I won't be needing either!
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redbird Guru Offline I Love YaBB 2! Posts: 862	Re: Local Anesthetics Reply #12 - 09/11/12 at 04:15:27 I would think long and hard about not carry epi...when I have an attack I would never be able to draw a dose or that it would be the right amount..I shake so bad
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redbird

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Re: Local Anesthetics
Reply #13 - 09/11/12 at 04:21:09

wellllll wanted to comment on Joan's remarks on this ...but don't know how to post it here BUT...

she is correct...epi will bring blood pressure down if it is up...and if the B P is down it will bring it up...something to remember if you are laying on that gurney and the doctor is shaking his head...saying ...what shall we do...been there done that
redbird

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redbird Guru Offline I Love YaBB 2! Posts: 862	Re: Local Anesthetics Reply #14 - 09/11/12 at 04:25:41 WOW...another thing to remember is..... bendryl should ALWAYS be given to you SLOWLY...if it is an injection..over 2 minutes and this instruction is listed in my treatment papers..if not for a masto person it can mess with the heart or as mentioned your breathing..
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