Subcutaneous Lidocaine Infusion for Pain in Patients with Cancer

Lidocaine Infusion: An Analgesic Option for Checkpoint Inhibitor Arthritis: A Case Report

This report describes the use of subcutaneous lidocaine infusion to manage complex pain associated with checkpoint inhibitor inflammatory arthritis. In addition, the safe administration of lidocaine in the home setting is described. A 49-year-old man with metastatic melanoma to lung, right axilla and posterior chest wall on regular pembrolizumab developed checkpoint inhibitor inflammatory arthritis. Pain associated with this was unresponsive to simple analgesia, escalating opioids and adjuvant analgesics. Lidocaine infusion was used on separate occasions (inpatient unit and home setting) to gain rapid and sustained control of inflammatory pain. Inflammatory pain responded well to 2 mg/kg/h lidocaine infusion over 4 days with sustained response between infusions of up to 6 wk. Resulting in improved mobility, functional status, and overall quality of life. Lidocaine infusion should be considered as an option for analgesic management of checkpoint inhibitor inflammatory arthritis in patients for whom usual treatment is ineffective, and as an opioid-sparing intervention.

Lidocaine exerts anticancer activity in bladder cancer by targeting isoprenylcysteine carboxylmethyltransferase (ICMT)

Background

Bladder cancer is one of the most common malignant tumors among humans and has a high mortality. Clinically, lidocaine is the most commonly used local anesthetic, which can inhibit the proliferation of bladder cancer cells; however, its downstream specific molecular mechanisms are unclear.

Methods

The SwissTarget and TargetNet databases were used to analyze the target of lidocaine. The online public cancer transcriptome database UALCAN was used to analyze the up-regulated genes in The Cancer Genome Atlas Urothelial Bladder Carcinoma (TCGA-BLCA) data collection, and the intersection of the 2 was used to obtain the core target. The only target, isoprenylcysteine carboxylmethyltransferase (ICMT), was obtained by combining the correlation between the target and the clinical information of bladder cancer and the Kaplan-Meier (K-M) survival curve. Then, UMUC3 and T24 cells were selected as research vectors in vitro. Cell proliferation, cell cycle, and apoptosis were detected by cell counting kit-8, colony formation, flow cytometry, and western blotting.

Results

Network pharmacology analysis showed that ICMT might be one of the targets of lidocaine, and the expression level of ICMT was closely related to the clinical phenotype of bladder cancer. Lidocaine treatment (4 and 8 mM) significantly inhibited the proliferation of UMUC3 and T24 cells, promoted apoptosis, and significantly inhibited the mass and volume of xenograft tumors. In vitro experiments showed that ICMT promoted the proliferation of UMUC3 and T24 cells. Lidocaine inhibited the expression of ICMT in UMUC3 and T24 cells in a concentration and time-dependent manner, and inhibited cell proliferation by down-regulating ICMT expression.

Conclusions

Lidocaine exerts anti-tumor effect by down-regulating the expression of ICMT in bladder cancer.

Parenteral Lidocaine for Complex Cancer Pain in the Home or Inpatient Hospice Setting: A Review and Synthesis of the Evidence

Background: Cancer pain can remain refractory despite escalating opioids and adjuvants. Systemic Lidocaine is an option, but current approaches are hospital centered. While advantageous in advanced cancer, evidence is lacking for parenteral Lidocaine use in community-based care. Objectives: Review evidence for parenteral lidocaine in complex cancer pain outside the hospital setting. Design: Systematic review of peer-reviewed articles of any study design, including reviews. Search in four databases used keyword variations of "cancer," "pain," "Lidocaine," and "parenteral." Search was extended through reference lists of full texts assessed. Abstracted data from articles screened and selected were synthesized narratively by a palliative care clinician in Singapore. Results: Eight hundred eighty-three articles identified were screened by title and abstract. Twenty-eight full texts were assessed. Seven articles fulfilled criteria for synthesis of findings. A total of 73 patients received parenteral Lidocaine for mixed pains, reported collectively in 1 retrospective chart review, 3 practice guidelines, 2 case series, and 1 case study. Intravenous or subcutaneous Lidocaine was commenced in hospital or hospice and continued at home. Dosages and administration schedules varied, involving slow bolus with continuous infusion or the latter alone, for up to 240 days. All produced positive outcomes, with no severe adverse events. Monitoring included routine vital signs and conscious levels; electrocardiogram, liver, and renal function tests were uncommon. Lidocaine levels were not consistently assessed. Conclusion: Parenteral Lidocaine can be effective and safe in the community setting. More empirical studies are needed to inform patient selection and treatment protocol, and to validate expected outcomes.

Lidocaine Infusions for Pain Management in Pediatrics

Lidocaine is an amino amide with a well-established role as a local anesthetic agent. Systemic intravenous administration expands its clinical use to include acute and chronic pain circumstances, such as postoperative pain, neuropathic pain, postherpetic neuralgia, hyperalgesia, visceral pain, and centrally mediated pain. For refractory pain that has not responded to conventional therapy or if further escalation of treatment is prevented by contraindications or side effects to standard therapies, a continuous infusion of lidocaine may be considered as a single intervention or as a sequence of infusions. Here, we review and evaluate published data reflecting the use of lidocaine continuous infusions for pain management in the pediatric population.

Subcutaneous Lidocaine Infusion for Complex Cancer Pain: A Retrospective Review

This retrospective review assesses the safety and efficacy of subcutaneous lidocaine infusions for complex cancer pain, in a specialist palliative care unit. A retrospective chart review was undertaken of 18 infusions over a 2-year period. Data collected included patient demographics, use of adjuvant analgesics, methadone use and opioid requirements (as oral morphine equivalent daily dose, oMEDD) at three time periods: 24 hours prior to starting infusion, 24 hours after starting infusion and 24 hours after stopping infusion. Data was collected on infusion characteristics, adverse events and the patient's perception of lidocaine efficacy. Eighteen infusions were analyzed; all patients had metastatic cancer with 83.3% having stage IV disease. The majority of patients were prescribed three or more adjuvant analgesics, in addition, methadone was prescribed in 16 oMEDD use both 24 hours after starting, and 24 hours after stopping the lidocaine infusions. Events were reported in three out of 18 infusions, only one minor adverse event was attributed to lidocaine. Thirteen out of 18 infusions were perceived, by patients, to be effective for pain. This retrospective review has shown that a subcutaneous lidocaine infusion is a safe and effective means of managing complex cancer pain in a specialist palliative care unit.

Local Anesthetic Lidocaine and Cancer: Insight Into Tumor Progression and Recurrence

Cancer is a leading contributor to deaths worldwide. Surgery is the primary treatment for resectable cancers. Nonetheless, it also results in inflammatory response, angiogenesis, and stimulated metastasis. Local anesthetic lidocaine can directly and indirectly effect different cancers. The direct mechanisms are inhibiting proliferation and inducing apoptosis via regulating PI3K/AKT/mTOR and caspase-dependent Bax/Bcl2 signaling pathways or repressing cytoskeleton formation. Repression invasion, migration, and angiogenesis through influencing the activation of TNFα-dependent, Src-induced AKT/NO/ICAM and VEGF/PI3K/AKT signaling pathways. Moreover, the indirect influences are immune regulation, anti-inflammation, and postoperative pain relief. This review summarizes the latest evidence that revealed potential clinical benefits of lidocaine in cancer treatment to explore the probable molecular mechanisms and the appropriate dose.

Lidocaine Continuous Subcutaneous Infusion for Neuropathic Pain in Hospice Patients: Safety and Efficacy

Lidocaine continuous subcutaneous infusion (L-CSCI) for neuropathic pain in hospice patients has limited evidence for its safety and efficacy, and guidelines are lacking. This study assesses a series of patients admitted to a hospice over a six-month period that had neuropathic pain and received L-CSCI. The primary outcome was improvement in patient-rated distress from pain following L-CSCI titration. Also assessed were changes in oral morphine equivalent dose (OME), frequency of breakthrough medication, functional status, adverse effects and perception of response. Fifteen patients received L-CSCI for an average of 6.7 days (range 1-92). Average pain distress score decreased by 2 or more in six patients. Positive responses to L-CSCI were documented in the clinical notes of 10 patients. Opioid down-titration occurred in four patients. Lidocaine levels were performed in 3 patients but did not change management. Five patients experienced adverse effects attributable to lidocaine and all responded to simple measures. In conclusion, L-CSCI can help manage neuropathic pain in hospice patients, particularly in those who cannot swallow oral medications. Further systematic research is warranted to establish efficacy and tolerability, and to inform guideline development.

[Pediatric pain treatment and prevention for hospitalized children]

INTRODUCTION

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

OBJECTIVES

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

METHODS

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable "Factsheet Pain in Children: Management" and reviews best evidence and practice.

RESULTS

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind-body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

CONCLUSION

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

Lidocaine improves cerebral ischemia-reperfusion injury in rats through cAMP/PKA signaling pathway

Influence of lidocaine on rats with cerebral ischemia-reperfusion injury (CIRI) was studied to explore its mechanism of action. A total of 30 Sprague-Dawley rats were randomly divided into control group and model group, and the rat model of CIRI was prepared by the suture-occluded method in the model group. Then the rats in the model group were randomly assigned into the model group (n=10) and the lidocaine group (n=10). The neurological function score of rats was evaluated, and the levels of serum B-cell lymphoma-2 (Bcl-2) and Bcl-2 associated X protein (Bax) in rats were determined using ELISA. TUNEL assay was performed to detect the neuronal apoptosis in the brain of rats. The messenger ribonucleic acid (mRNA) and protein expression levels of cyclic adenosine monophosphate (cAMP) and protein kinase A (PKA) were measured via RT-PCR and western blotting, respectively. Compared with those in the control group, the rats in the model group had an elevated neurological function score, a raised level of Bcl-2, but a reduced level of Bax in the serum, an obviously increased rate of neuronal apoptosis in the brain and decreased mRNA and protein levels of cAMP and PKA in cerebral tissues. The rats in lidocaine group had a lower neurological function score, a lower level of Bcl-2, but a higher level of Bax in the serum, an evidently lower rate of neuronal apoptosis in the brain and higher mRNA and protein levels of cAMP and PKA in cerebral tissues than those in the model group. Lidocaine can improve the neurological function of rats with CIRI and inhibit neuronal apoptosis in the brain, and its mechanism of action may be related to the activation of the cAMP/PKA signaling pathway.

Lidocaine inhibits the proliferation and invasion of hepatocellular carcinoma by downregulating USP14 induced PI3K/Akt pathway

Previous studies have found that Lidocaine (Lido) has marked anti-tumor effects. The purpose of this study was to explore the effect and mechanism of Lido on hepatocellular carcinoma (HCC). Here, the Huh-7 and SMMC-7721 HCC cells were treated with Lido, then the proliferation, migration and invasion of HCC cells were detected by CCK8, wounding healing assay and Transwell assay. Besides, apoptotic proteins (including Caspase3 and Bcl2), epithelial-mesenchymal transition (EMT) associated markers (including E-cadherin and Vimentin), USP14, PI3K/Akt pathway were detected by western blot. Our results revealed that Lido significantly inhibited the proliferation, migration and invasion while aggravate the apoptosis of HCC cells, as well as the expression of USP14 and the activation of PI3K/Akt. Loss-of-function experiments confirmed that USP14 downregulation attenuated the malignant behaviors of HCC cells through repressing PI3K/Akt signaling pathway. Mechanistically, USP14 functioned by deubiquitinating and activating PI3K. In conclusion, Lido inhibits the proliferation and metastasis of HCC cells by targeting USP14 and its downstream PI3K/Akt signaling pathway.

Pediatric pain treatment and prevention for hospitalized children

Introduction:

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

Objectives:

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

Methods:

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable “Factsheet Pain in Children: Management” and reviews best evidence and practice.

Results:

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind–body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

Conclusion:

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

Recent advances in pain treatment for children with serious illness

Pain is a common distressing symptom in children receiving pediatric palliative care. Both in children with cancer, but especially in children with progressive neurodegenerative and chromosomal conditions with CNS impairment pain is common, and often under-recognized and undertreated. Multimodal analgesia for children with serious illness acts synergistically for more effective pediatric pain and symptom control with fewer side effects than a single analgesic or modality. Successful pain treatment and prevention usually include integrative 'nonpharmacological' therapies, rehabilitation, psychology and spirituality in addition to pharmacology and regional anesthesia. This review article will address these effective components of multimodal pediatric analgesia and present starting doses of basic analgesia, opioids and adjuvants analgesia in infants, children and adolescents with serious illness.

Does continuous subcutaneous infusion of lignocaine relieve intractable pruritus associated with advanced cutaneous T-cell lymphoma? A retrospective case series review

BACKGROUND

Intractable pruritus affects an estimated 83% of patients with advanced cutaneous T-cell lymphoma. Palliative care strategies to improve outcomes for these patients are lacking. Lignocaine antagonises kappa opioid antagonist-induced scratching in mice models and may relieve cutaneous T-cell lymphoma-pruritus.

PRACTICE CHALLENGE

The aim of this retrospective case series was to evaluate our clinical experience with low-dose continuous subcutaneous infusion lignocaine for intractable pruritus associated with cutaneous T-cell lymphoma, from 2000 to 2015. The study received approval from Retrospective Review Panel, Division Cancer Medicine, 12 October 2015, V1.1.

METHOD

Baseline demographics including cutaneous T-cell lymphoma diagnosis and management, comorbidities, and pruritus-related evaluation including onset, severity, past and current therapies were collected. Response categories (Complete, Partial, No, Unknown) were devised for the study, based on severity of pruritus, impact on sleep and mood. The mean of responses was calculated for each patient and across the series.

OUTCOME

Nineteen patients received continuous subcutaneous infusion lignocaine, in 45 treatment episodes, ranging from 1 to 70 days (interquartile range = 5). Baseline mean number of adjuvants was 3.9 (range, 1-9). Across the series, complete response was achieved, on average, 26.7% days, partial response 49.4%, no response 16.1% and unknown response 9.2%. Drowsiness was documented in four patients. Three patients died during continuous subcutaneous infusion due to disease progression.

LESSONS

Continuous subcutaneous infusion lignocaine offers another therapeutic option in cutaneous T-Cell lymphoma-related intractable pruritus.

FUTURE RESEARCH

Prospective studies using validated assessment tools and systematic approaches to pruritus management are required.

Comparative Efficacy of Therapeutics for Chronic Cancer Pain: A Bayesian Network Meta-Analysis

PURPOSE

Opioids are the primary choice for managing chronic cancer pain. However, many nonopioid therapies are currently prescribed for chronic cancer pain with little published evidence comparing their efficacy.

METHODS

Electronic databases were searched for randomized controlled trials (RCTs) comparing any systemic pharmaceutical intervention and/or combination thereof in treating chronic cancer pain. The primary outcome was global efficacy reported as an odds ratio (OR). The secondary outcome was change in pain intensity reported as a standardized mean difference (SMD).

RESULTS

We included 81 RCTs consisting of 10,003 patients investigating 11 medication classes. Most RCTs (80%) displayed low risk of bias. The top-ranking classes for global efficacy were nonopioid analgesics (network OR, 0.30; 95% credibility interval [CrI], 0.13 to 0.67), nonsteroidal anti-inflammatory drugs (network OR, 0.44; 95% CrI, 0.22 to 0.90), and opioids (network OR, 0.49; 95% CrI, 0.27 to 0.86), whereas the top-ranked interventions were lidocaine (network OR, 0.04; 95% CrI, 0.01 to 0.18; surface under the cumulative ranking curve analysis [SUCRA] score, 98.1), codeine plus aspirin (network OR, 0.22; 95% CrI, 0.08 to 0.63; SUCRA score, 81.1), and pregabalin (network OR, 0.29; 95% CrI, 0.08 to 0.92; SUCRA score, 73.8). In terms of reducing pain intensity, we found that no class was superior to placebo, whereas the following top-ranked interventions were superior to placebo: ziconotide (network SMD, −24.98; 95% CrI, −32.62 to −17.35; SUCRA score, 99.8), dezocine (network SMD, −13.56; 95% CrI, −23.37 to −3.69; SUCRA score, 93.5), and diclofenac (network SMD, −11.22; 95% CrI, −15.91 to −5.80; SUCRA score, 92.9).

CONCLUSION

There are significant differences in efficacy among current regimens for chronic cancer pain. Our evidence suggests that certain nonopioid analgesics and nonsteroidal anti-inflammatory drugs can serve as effectively as opioids in managing chronic cancer pain.