How do I write an order for lidocaine (local anesthetic) patches?

How to Write an Order for Lidocaine Patches

Order lidocaine 5% patches: Apply up to 3 patches to the painful area for 12 hours on, then 12 hours off each day, applied to intact skin only. 1

Essential Order Components

Basic Prescription Format

• Medication: Lidocaine 5% patch (prescription strength) or Lidocaine 4% patch (over-the-counter) 2, 3
• Quantity: Up to 3-4 patches per 24-hour period 2, 3
• Application schedule: 12 hours on, 12 hours off 2, 4
• Site: Apply to area of greatest pain on intact skin only 1, 3
• Duration: Specify treatment duration (typically 28 days initially, then reassess) 5

Sample Order Language

"Lidocaine 5% patch: Apply up to 3 patches to [specify painful area] for 12 hours daily. Remove all patches after 12 hours and allow 12-hour patch-free interval. Apply to intact skin only. Dispense: [90 patches for 30-day supply]" 1, 2

Critical Safety Considerations Before Prescribing

Absolute Contraindications

• Advanced liver failure (lidocaine clearance reduced by 60%) 2, 3
• Known allergy to amide-type anesthetics 2
• Application to broken, inflamed, or non-intact skin 2, 3
• Patients weighing less than 40 kg 1, 2

Relative Contraindications (Use with Caution)

• Cardiac disease or electrolyte disorders 1, 2
• Seizure disorders 1, 2
• Renal impairment 1, 2
• Pregnancy or breastfeeding 1
• Neurological disorders 1, 2
• Age >70 years 2

Dosing and Application Instructions

Maximum Safe Dosing

• Up to 4 patches maximum in 24 hours maintain plasma levels within safe range 2, 3
• Never exceed 3-4 patches simultaneously depending on painful area size 3, 6
• Each patch contains 700 mg lidocaine (5% formulation) 4, 6

Application Technique

• Apply patches directly to the most painful area 1, 5
• Can be applied to head/neck, trunk (chest, abdomen, back, hips), or extremities 7
• Head/neck applications have higher adverse event rates compared to trunk or extremities 7
• Patches may be cut to fit smaller areas if needed 4

Critical Drug Interaction Warning

Avoid Concurrent Local Anesthetics

Never combine lidocaine patches with other local anesthetic interventions without appropriate time intervals: 1, 2

• Remove all lidocaine patches at least 4 hours before any nerve block, fascial plane block, or infiltration 1, 2
• Do not start patches within 4 hours of any local anesthetic procedure 1, 2
• If using IV lidocaine, remove all topical patches before starting infusion 1, 2, 3
• Calculate total dose of all local anesthetics to prevent cumulative toxicity 1, 2

Patient Education Requirements

What to Tell Patients

• Application: Apply to clean, dry, intact skin; remove after exactly 12 hours 2, 4
• Avoid heat: Do not apply heating pads or heat sources over patches (increases systemic absorption) 3
• Storage: Keep in child-resistant packaging 8
• Combination products: Avoid over-the-counter lidocaine creams or preparations while using patches 2

Toxicity Warning Signs

Instruct patients to remove patches immediately and seek emergency care if they experience: 1, 2

• Circumoral numbness or facial tingling 1, 2
• Tongue or lip tingling 1, 2
• Tinnitus or auditory disturbances 1, 2
• Light-headedness or dizziness 1, 2
• Slurred speech 1, 2
• Confusion or altered mental status 2
• Muscle twitching 1, 2

Expected Efficacy Timeline

Response Assessment

• By Day 7: Approximately 66% of patients report pain improvement 5
• By Day 14: An additional 43% of non-responders may show improvement 5
• Final assessment: About 60% achieve moderate to complete pain relief 5
• Reassess at 28 days and consider alternative or adjunctive therapy if inadequate response 5

Common Pitfalls to Avoid

Prescription Errors

• Do not prescribe for patients <40 kg (increased toxicity risk) 1, 2
• Do not allow continuous 24-hour application without the 12-hour off period 2, 4
• Do not prescribe more than 4 patches per day (exceeds safe plasma levels) 2, 6

Application Site Issues

• Mild erythema is common and expected at application sites 4, 6
• Head/neck applications have higher rates of local adverse events but similar efficacy 7
• Patches work equally well regardless of time since pain onset 5

Adjunctive Therapy Considerations

When Patches Alone Are Insufficient

Lidocaine patches are frequently used as co-analgesics in combination with: 1

• Opioids for baseline pain control 1
• Gabapentin (starting 100-300 mg nightly, titrate to 900-3600 mg daily) for neuropathic component 1
• Pregabalin (starting 50 mg three times daily, titrate to 100 mg three times daily) 1
• Tricyclic antidepressants (nortriptyline 10-25 mg nightly, titrate to 50-150 mg) 1