From the Guidelines
Cross-reactivity between bupivacaine and lidocaine is rare, and patients allergic to one local anesthetic can typically safely receive the other. These medications belong to different subclasses of amide-type anesthetics, but the key point is that true allergic reactions to local anesthetics occur in less than 1% of all adverse reactions, with most reactions being vasovagal responses or inadvertent intravascular injection effects rather than true allergies 1.
Key Points to Consider
- If a patient reports an allergy to one amide local anesthetic, consider using a local anesthetic from the ester class (such as procaine or tetracaine) to completely avoid potential cross-reactivity.
- For patients with confirmed allergies, skin testing can be performed by an allergist to determine safe alternatives.
- The structural differences between specific amide anesthetics often allow for safe use of another medication in the same class.
- When administering local anesthetics to patients with reported allergies, have emergency medications (epinephrine, antihistamines, corticosteroids) readily available and consider a test dose with careful monitoring before proceeding with the full dose.
Clinical Implications
Given the low risk of cross-reactivity and the rarity of true allergic reactions, bupivacaine can be considered a safe alternative for patients allergic to lidocaine, and vice versa, provided that proper precautions and monitoring are in place 1. It's also important to note that the use of bacteriostatic saline or diphenhydramine as alternatives may be useful in certain situations, such as small excisions and biopsies, but these options have their own limitations and potential drawbacks 1.
From the FDA Drug Label
Cross sensitivity among members of the amide-type local anesthetic group has been reported. The cross-reactivity between bupivacaine and lidocaine is possible due to cross sensitivity among members of the amide-type local anesthetic group.
- Key points:
- Bupivacaine and lidocaine are both amide-type local anesthetics.
- Cross sensitivity has been reported among this group.
- This means that patients who are allergic to one amide-type local anesthetic may also be allergic to others, including bupivacaine and lidocaine 2
From the Research
Cross-Reactivity Between Bupivacaine and Lidocaine
- The cross-reactivity between bupivacaine and lidocaine is a significant concern in patients with a history of allergy to local anesthetics 3.
- A study reported a case of a patient who suffered itching and generalized urticaria with facial angioedema after administration of mepivacaine, and skin tests revealed a strong positive reaction to mepivacaine, lidocaine, and ropivacaine, but negative reactions to bupivacaine and levobupivacaine 4.
- Another study reported a case of a patient who suffered anaphylaxis after receiving regional anesthesia with levobupivacaine and ropivacaine, and skin testing revealed positive reactions to both levobupivacaine and ropivacaine, and negative reactions to articaine and lidocaine 5.
- A case series reported the management of labor analgesia in patients with a history of lidocaine allergy using chloroprocaine patient-controlled epidural analgesia (PCEA), due to the potential cross-reactivity between lidocaine and bupivacaine 3.
- A clinical comparative study evaluated the efficacy of lidocaine versus a combination of lidocaine and bupivacaine in the management of maxillofacial trauma, and found that the combination of lidocaine and bupivacaine had a longer duration of action and required a lesser volume of anesthetic solution 6.