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LIDOCAINE and PRILOCAINE CREAM, 2.5%/2.5%

NOT FOR OPHTHALMIC USE
FOR EXTERNAL USE ONLY

Rx only

DESCRIPTION

Lidocaine and prilocaine cream, 2.5%/2.5% is an emulsion in which the oil phase is a eutectic mixture of lidocaine and prilocaine in a ratio of 1:1 by weight. This eutectic mixture has a melting point below room temperature and therefore both local anesthetics exist as a liquid oil rather than as crystals. It is packaged in 30 gram tubes and 5 gram tubes for hospital use. Lidocaine is chemically designated as acetamide, 2-(diethylamino)-N-(2,6-dimethylphenyl), has an octanol:water partition ratio of 43 at pH 7.4, and has the following structure:

Prilocaine is chemically designated as propanamide, N-(2-methylphenyl)-2-(propylamino), has an octanol:water partition ratio of 25 at pH 7.4, and has the following structure:

Each gram of lidocaine and prilocaine cream, 2.5%/2.5% contains lidocaine 25 mg, prilocaine 25 mg, polyoxyethylene fatty acid esters (as emulsifiers), carbomer 934 (as a thickening agent), sodium hydroxide to adjust to a pH approximating 9, and purified water. Lidocaine and prilocaine cream, 2.5%/2.5% contains no preservative, however it passes the USP antimicrobial effectiveness test due to the pH. The specific gravity of lidocaine and prilocaine cream, 2.5%/2.5% is approximately 1.

CLINICAL PHARMACOLOGY

CLINICAL STUDIES

Lidocaine and prilocaine cream, 2.5%/2.5% application in adults prior to IV cannulation or venipuncture was studied in 200 patients in four clinical studies in Europe. Application for at least 1 hour provided significantly more dermal analgesia than placebo cream or ethyl chloride. Lidocaine and prilocaine cream, 2.5%/2.5% was comparable to subcutaneous lidocaine, but was less efficacious than intradermal lidocaine. Most patients found lidocaine and prilocaine cream, 2.5%/2.5% treatment preferable to lidocaine infiltration or ethyl chloride spray.

Lidocaine and prilocaine cream, 2.5%/2.5% was compared with 0.5% lidocaine infiltration prior to skin graft harvesting in one open label study in 80 adult patients in England. Application of lidocaine and prilocaine cream, 2.5%/2.5% for 2 to 5 hours provided dermal analgesia comparable to lidocaine infiltration.

Lidocaine and prilocaine cream, 2.5%/2.5% application in children was studied in seven non-US studies (320 patients) and one US study (100 patients). In controlled studies, application of lidocaine and prilocaine cream, 2.5%/2.5% for at least 1 hour with or without presurgical medication prior to needle insertion provided significantly more pain reduction than placebo. In children under the age of seven years, lidocaine and prilocaine cream, 2.5%/2.5% was less effective than in older children or adults.

Lidocaine and prilocaine cream, 2.5%/2.5% was compared with placebo in the laser treatment of facial port-wine stains in 72 pediatric patients (ages 5-16). Lidocaine and prilocaine cream, 2.5%/2.5% was effective in providing pain relief during laser treatment.

Lidocaine and prilocaine cream, 2.5%/2.5% alone was compared to lidocaine and prilocaine cream, 2.5%/2.5% followed by lidocaine infiltration and lidocaine infiltration alone prior to cryotherapy for the removal of male genital warts. The data from 121 patients demonstrated that lidocaine and prilocaine cream, 2.5%/2.5% was not effective as a sole anesthetic agent in managing the pain from the surgical procedure. The administration of lidocaine and prilocaine cream, 2.5%/2.5% prior to lidocaine infiltration provided significant relief of discomfort associated with local anesthetic infiltration and thus was effective in the overall reduction of pain from the procedure only when used in conjunction with local anesthetic infiltration of lidocaine.

Lidocaine and prilocaine cream, 2.5%/2.5% was studied in 105 full term neonates (gestational age: 37 weeks) for blood drawing and circumcision procedures. When considering the use of lidocaine and prilocaine cream, 2.5%/2.5% in neonates, the primary concerns are the systemic absorption of the active ingredients and the subsequent formation of methemoglobin. In clinical studies performed in neonates, the plasma levels of lidocaine, prilocaine, and methemoglobin were not reported in a range expected to cause clinical symptoms.

Local dermal effects associated with lidocaine and prilocaine cream, 2.5%/2.5% application in these studies on intact skin included paleness, redness and edema and were transient in nature (see ADVERSE REACTIONS).

The application of lidocaine and prilocaine cream, 2.5%/2.5% on genital mucous membranes for minor, superficial surgical procedures (eg, removal of condylomata acuminata) was studied in 80 patients in a placebo-controlled clinical trial (60 patients received lidocaine and prilocaine cream, 2.5%/2.5% and 20 patients received placebo). Lidocaine and prilocaine cream, 2.5%/2.5% (5 to 10 g) applied between 1 and 75 minutes before surgery, with a median time of 15 minutes, provided effective local anesthesia for minor superficial surgical procedures. The greatest extent of analgesia, as measured by VAS pain scores, was attained after 5 to 15 minutes. The application of lidocaine and prilocaine cream, 2.5%/2.5% to genital mucous membranes as pretreatment for local anesthetic infiltration was studied in a double-blind, placebo-controlled study in 44 female patients (21 patients received lidocaine and prilocaine cream, 2.5%/2.5% and 23 patients received placebo) scheduled for infiltration prior to a surgical procedure of the external vulva or genital mucosa. Lidocaine and prilocaine cream, 2.5%/2.5% applied to the genital mucous membranes for 5 to 10 minutes resulted in adequate topical anesthesia for local anesthetic injection.

INDICATIONS AND USAGE

Lidocaine and prilocaine cream, 2.5%/2.5% (a eutectic mixture of lidocaine 2.5% and prilocaine 2.5%) is indicated as a topical anesthetic for use on:

  •  - normal intact skin for local analgesia.
  •  - genital mucous membranes for superficial minor surgery and as pretreatment for infiltration anesthesia. Lidocaine and prilocaine cream, 2.5%/2.5% is not recommended in any clinical situation in which penetration or migration beyond the tympanic membrane into the middle ear is possible because of the ototoxic effects observed in animal studies (see WARNINGS).

CONTRAINDICATIONS

Lidocaine and prilocaine cream, 2.5%/2.5% is contraindicated in patients with a known history of sensitivity to local anesthetics of the amide type or to any other component of the product.

WARNINGS

Application of lidocaine and prilocaine cream, 2.5%/2.5% to larger areas or for longer times than those recommended could result in sufficient absorption of lidocaine and prilocaine resulting in serious adverse effects (see Individualization of Dose).

Patients treated with class III anti-arrhythmic drugs (eg, amiodarone, bretylium, sotalol, dofetilide) should be under close surveillance and ECG monitoring considered, because cardiac effects may be additive.

Studies in laboratory animals (guinea pigs) have shown that lidocaine and prilocaine cream, 2.5%/2.5% has an ototoxic effect when instilled into the middle ear. In these same studies, animals exposed to lidocaine and prilocaine cream, 2.5%/2.5% in the external auditory canal only, showed no abnormality. Lidocaine and prilocaine cream, 2.5%/2.5% should not be used in any clinical situation in which its penetration or migration beyond the tympanic membrane into the middle ear is possible.

PRECAUTIONS

Carcinogenesis, Mutagenesis, Impairment of Fertility

Use in Pregnancy: Teratogenic Effects: Pregnancy Category B.

Reproduction studies with lidocaine have been performed in rats and have revealed no evidence of harm to the fetus (30 mg/kg subcutaneously; 22 times SDA). Reproduction studies with prilocaine have been performed in rats and have revealed no evidence of impaired fertility or harm to the fetus (300 mg/kg intramuscularly; 188 times SDA). There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, lidocaine and prilocaine cream, 2.5%/2.5% should be used during pregnancy only if clearly needed.

Reproduction studies have been performed in rats receiving subcutaneous administration of an aqueous mixture containing lidocaine HCl and prilocaine HCl at 1:1 (w/w). At 40 mg/kg each, a dose equivalent to 29 times SDA lidocaine and 25 times SDA prilocaine, no teratogenic, embryotoxic or fetotoxic effects were observed.

Geriatric Use

Of the total number of patients in clinical studies of lidocaine and prilocaine cream, 2.5%/2.5%, 180 were age 65 to 74 and 138 were 75 and over. No overall differences in safety or efficacy were observed between these patients and younger patients. Other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

Plasma levels of lidocaine and prilocaine in geriatric and non-geriatric patients following application of a thick layer of lidocaine and prilocaine cream, 2.5%/2.5% are very low and well below potentially toxic levels. However, there are no sufficient data to evaluate quantitative differences in systemic plasma levels of lidocaine and prilocaine between geriatric and non-geriatric patients following application of lidocaine and prilocaine cream, 2.5%/2.5%. Consideration should be given for those elderly patients who have enhanced sensitivity to systemic absorption. (See PRECAUTIONS.)

After intravenous dosing, the elimination half-life of lidocaine is significantly longer in elderly patients (2.5 hours) than in younger patients (1.5 hours). (See CLINICAL PHARMACOLOGY.)

ADVERSE REACTIONS

OVERDOSAGE

Peak blood levels following a 60 g application to 400 cm2 of intact skin for 3 hours are 0.05 to 0.16 mcg/mL for lidocaine and 0.02 to 0.10 mcg/mL for prilocaine. Toxic levels of lidocaine (>5 mcg/mL) and/or prilocaine (>6 mcg/mL) cause decreases in cardiac output, total peripheral resistance and mean arterial pressure. These changes may be attributable to direct depressant effects of these local anesthetic agents on the cardiovascular system. In the absence of massive topical overdose or oral ingestion, evaluation should include evaluation of other etiologies for the clinical effects or overdosage from other sources of lidocaine, prilocaine or other local anesthetics. Consult the package inserts for parenteral Xylocaine (lidocaine HCl) or Citanest (prilocaine HCl) for further information for the management of overdose.

DOSAGE AND ADMINISTRATION

Adult Patients-Intact Skin

A thick layer of lidocaine and prilocaine cream, 2.5%/2.5% is applied to intact skin and covered with an occlusive dressing.

Adult Female Patients-Genital Mucous Membranes

For minor procedures on the female external genitalia, such as removal of condylomata acuminata, as well as for use as pretreatment for anesthetic infiltration, apply a thick layer (5-10 grams) of lidocaine and prilocaine cream, 2.5%/2.5% for 5 to 10 minutes.

Occlusion is not necessary for absorption, but may be helpful to keep the cream in place. Patients should be lying down during the lidocaine and prilocaine cream, 2.5%/2.5% application, especially if no occlusion is used. The procedure or the local anesthetic infiltration should be performed immediately after the removal of lidocaine and prilocaine cream, 2.5%/2.5%.

Pediatric Patients-Intact Skin

The following are the maximum recommended doses, application areas and application times for lidocaine and prilocaine cream, 2.5%/2.5% based on a child's age and weight:

Please note: If a patient greater than 3 months old does not meet the minimum weight requirement, the maximum total dose of lidocaine and prilocaine cream, 2.5%/2.5% should be restricted to that which corresponds to the patient's weight.

Practitioners should carefully instruct caregivers to avoid application of excessive amounts of lidocaine and prilocaine cream, 2.5%/2.5% (see PRECAUTIONS).

When applying lidocaine and prilocaine cream, 2.5%/2.5% to the skin of young children, care must be taken to maintain careful observation of the child to prevent accidental ingestion of lidocaine and prilocaine cream, 2.5%/2.5% or the occlusive dressing. A secondary protective covering to prevent inadvertent disruption of the application site may be useful.

Age and Body Weight RequirementsMaximum total Dose of
Lidocaine and
Prilocaine Cream, 2.5%/2.5%
Maximum
Application Area
Maximum
Application Time
0 up to 3 months or < 5 kg1g10 cm21 hour
3 up to 12 months and >5 kg2g20 cm24 hours
1 to 6 years and >10 kg10g100 cm24 hours
7 to 12 years and >20 kg20g200 cm24 hours

Lidocaine and prilocaine cream, 2.5%/2.5% should not be used in neonates with a gestational age less than 37 weeks nor in infants under the age of twelve months who are receiving treatment with methemoglobin-inducing agents (see Methemoglobinemia subsection of WARNINGS).

When lidocaine and prilocaine cream, 2.5%/2.5% is used concomitantly with other products containing local anesthetic agents, the amount absorbed from all formulations must be considered (see Individualization of Dose). The amount absorbed in the case of lidocaine and prilocaine cream, 2.5%/2.5% is determined by the area over which it is applied and the duration of application under occlusion (see Table 2, ** footnote, in Individualization of Dose).

Although the incidence of systemic adverse reactions with lidocaine and prilocaine cream, 2.5%/2.5% is very low, caution should be exercised, particularly when applying it over large areas and leaving it on for longer than 2 hours. The incidence of systemic adverse reactions can be expected to be directly proportional to the area and time of exposure (see Individualization of Dose).

HOW SUPPLIED

Lidocaine and prilocaine cream, 2.5%/2.5% is available as follows

NDC 0168-0357-30      30 gram tube
NDC 0168-0357-55      5 gram tube, FOR HOSPITAL USE ONLY
NDC 0168-0357-56      5 gram tube, with 12 dressings, FOR HOSPITAL USE ONLY

NOT FOR OPHTHALMIC USE.

KEEP CONTAINER TIGHTLY CLOSED AT ALL TIMES WHEN NOT IN USE.

WARNING: Keep out of reach of children.

Store at 20°-25°C (68°-77°F) (See USP Controlled Room Temperature).

E.FOUGERA & CO.
a division of Altana Inc. 
Melville, New York 11747

I2357/IF2357C
R7/06
#42

INSTRUCTIONS FOR APPLICATION

Lidocaine and Prilocaine Cream, 2.5%/2.5%

  • In adults, apply 2.5 g of cream per 20 to 25 cm2 (approx. 2 in. by 2 in.) of skin in a thick layer at the site of the procedure. For pediatric patients, apply ONLY as prescribed by your physician. If your child is below the age of 3 months or small for their age, please inform your doctor before applying lidocaine and prilocaine cream, 2.5%/2.5%, which can be harmful, if applied over too much skin at one time in young children. If your child becomes very dizzy, excessively sleepy, or develops duskiness of the face or lips after applying lidocaine and prilocaine cream, 2.5%/2.5%, remove the cream and contact your physician at once.
  • Take the dressing (may be supplied in this package) or other occlusive dressing and remove the center cut-out piece.
  • Peel the paper liner from the dressing. (Instructions continued on reverse side.)
  • Cover the lidocaine and prilocaine cream, 2.5%/2.5% so that you get a thick layer underneath. Do not spread out the cream. Smooth down the dressing edges carefully and ensure it is secure to avoid leakage. (This is especially important when the patient is a child.)
  • The time of application can be marked directly on the occlusive dressing. Lidocaine and prilocaine cream, 2.5%/2.5% must be applied at least 1 hour before the start of a routine procedure and for 2 hours before the start of a painful procedure.
  • Remove the occlusive dressing, wipe off the lidocaine and prilocaine cream, 2.5%/2.5%, clean the entire area with an antiseptic solution and prepare the patient for the procedure. The duration of effective skin anesthesia will be at least 1 hour after removal of the occlusive dressing.

PRECAUTIONS

  • Do not apply near eyes or on open wounds.
  • Keep out of reach of children.

E.FOUGERA & CO.
a division of Altana Inc. 
Melville, New York 11747
R7/06

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