Chloroprocaine is a short-acting local anesthetic of the ester type, similar in structure to procaine. Chloroprocaine is indicated for infiltration anesthesia and peripheral, sympathetic, epidural, caudal, subarachnoid, intravenous regional (Bier's method) blocks, and ocular surface anesthesia. Chloroprocaine is not effective as a topical anesthetic.
General Administration Information
For storage information, see the specific product information within the How Supplied section.
Route-Specific Administration
Injectable Administration
-Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
-Specialized references should be consulted for specific procedures and administration techniques.
-Resuscitative equipment and drugs used in the management of adverse reactions should be immediately available while administering local anesthetics.
-Chloroprocaine is administered by infiltration or peripheral or sympathetic block techniques.
Other Injectable Administration
Peripheral or sympathetic block:
-A solution containing 1:200,000 epinephrine/chloroprocaine may be prepared by adding 0.1 mL of epinephrine 1 mg/mL injection to 20 mL of chloroprocaine injection that does not contain preservatives. Do not use solutions containing epinephrine for interdigital anesthesia.
-Inject slowly and with frequent aspirations to prevent intravascular injection.
Epidural Administration
-This route of administration should only be used by specially trained healthcare professionals. Specialized references should be consulted for specific procedures and administration techniques.
-Resuscitative equipment and drugs used in the management of adverse reactions should be immediately available while administering local anesthetics.
-May be given as intermittent epidural or caudal injection, continuous epidural infusion, or as patient controlled epidural analgesia.
-Placement of epidural catheter and administration should be at a site near the dermatomes covering the field of pain to decrease dose requirements and increase specificity.
-A test dose of 3 mL of a 3% injection or 5 mL of a 2% injection should be administered 5 minutes before administering the total dose. If the patient is moved in such a way as to displace the catheter, the test dose should be repeated. Inadvertent subarachnoid injection is indicated by motor paralysis and extensive sensory anesthesia.
Epidural or caudal block:
-Injections containing preservatives should not be used for epidural or caudal block. Discard any partially used injections that do not contain preservatives.
-Large single doses should be divided into fractional doses and injected slowly with frequent aspirations. Care should be taken to prevent intravascular or subarachnoid injection.
Epidural infusion:
-A controlled-infusion device must be used. For highly concentrated injections, an implantable controlled-microinfusion device is used. Monitor patients for several days after implantation of the device.
-Injections containing preservatives should not be used for epidural infusion. Discard any partially used injections that do not contain preservatives.
-Preservative-free 0.9% Sodium Chloride Injection is recommended for dilution.
-Implantable infusion device: Filling of the infusion device reservoir should only be done by fully trained and qualified healthcare professionals. Strict aseptic technique must be used. Withdraw dose from the ampule through a 5-micrometer (or smaller pore diameter) microfilter to avoid contamination with glass or other particles. Then remove filter needle and replace with a clean needle prior to injecting the reservoir. Ensure proper placement of the needle when filling the reservoir to avoid accidental overdosage.
-To avoid exacerbation of severe pain and/or reflux of CSF into the reservoir, avoid depletion of the reservoir.
Intrathecal Administration (Clorotekal ONLY)
-Clorotekal is only for intrathecal administration. Do not administer by any other parenteral route. The safety of administration via continuous spinal catheters has not been established.
-Use only during surgical procedures suitable for the short duration of action of chloroprocaine.
-Clorotekal is intended for single use only. Use a filter needle to draw up the product. Administer immediately after opening.
-Do not mix or dilute with other products. Do not substitute the product with a different chloroprocaine product.
-Storage: Discard any unused product. Protect from light. Do not freeze, heat, or autoclave.
Ophthalmic Administration
Iheezo 3% Ophthalmic Gel
-Apply dose topically to the ocular surface in the area of the planned procedure.
-Do not touch the dropper tip to any other surface due to a risk of contamination.
-Instruct patients to avoid touching the eye for a minimum of 10 to 20 minutes following administration to reduce the risk of accidental ocular injury.
-Not intended for patient self-administration. Administer only under direct supervision of a healthcare provider.
Like all local anesthetics, chloroprocaine can produce significant CNS and cardiovascular toxicity, particularly when high serum concentrations are achieved. Rapid absorption from the injection site, reduced tolerance, or unintentional intravascular injection of chloroprocaine may contribute to these toxicities.
Chloroprocaine-induced CNS toxicity usually presents with symptoms of CNS stimulation such as anxiety, apprehension, restlessness, nervousness, disorientation, confusion, dizziness, blurry vision, nausea, vomiting, tremor, shivering, and seizures. Overt progression to seizures occurs in approximately 0.1% of local anesthetic administrations. Subsequently, depressive symptoms can occur including drowsiness, unconsciousness, coma, and respiratory depression (possibly resulting in respiratory arrest). In some patients, the symptoms of CNS toxicity can be minor and transient. Chloroprocaine may cause neurological damage manifested as paresthesias, motor weakness, muscle paralysis, loss of sensitivity, and cauda equina syndrome. Seizures can be treated with IV benzodiazepines, although this should be done cautiously because these agents are also CNS depressants. Nausea was reported in less than 2% of patients who received a single intrathecal dose of chloroprocaine 50 mg during clinical trials. Dyspnea, oral paresthesia, oral hypoesthesia, peripheral neuropathy, perineal disorder and sexual dysfunction, akathisia, presyncope, burning sensation, spinal cord injury, hypoesthesia, dysesthesia, myoclonia, and phantom limb pain have been reported during postmarketing use.
Blood concentrations of local anesthetics achieved after therapeutic doses are associated with minimal changes in cardiac conduction, excitability, refractoriness, and contractility. If a higher blood concentration is achieved due to inadvertent intravascular administration or repeated doses, depression of cardiac excitability and contractility may cause AV block, arrhythmia exacerbation (e.g., ventricular arrhythmias), or cardiac arrest. With decreased myocardial contractility, peripheral vasodilation may occur, which may cause decreased cardiac output and hypotension. During clinical trials of intrathecally administered chloroprocaine, hypotension was reported in 4.9% of patients who received a single intrathecal dose of chloroprocaine 50 mg. Other cardiovascular reactions reported during postmarketing experience include hypertension and sinus tachycardia. Symptoms of local anesthetic CNS toxicity, such as dizziness, tongue numbness, visual impairment or disturbances, and muscular twitching appear to occur before cardiotoxic effects. CNS-mediated cardiac effects in addition to blockade of sodium, potassium, and calcium channels within the heart may be responsible for some adverse cardiac effects. Examples of other possible adverse cardiovascular effects include angina, QT prolongation, PR prolongation, atrial fibrillation, sinus bradycardia, palpitations, and cardiovascular collapse. Maternal seizures and cardiovascular collapse may occur following paracervical block in early pregnancy (i.e., as anesthesia for elective abortion) due to rapid systemic absorption. Intravenous bupivacaine or ropivacaine administration until CNS depressive effects occurred caused QTc interval prolongation in healthy volunteers. For example, intravenous infusion of ropivacaine and bupivacaine 10 mg/minute in a randomized, crossover fashion caused a mean QTc interval of 406 to 408 +/- 28 milliseconds from 394 to 397 +/- 23 milliseconds. In contrast, the mean QTc interval was unchanged after infusion of a normal saline placebo. The 12 adults received a total mean bupivacaine dose of 103 +/- 30 mg and a total mean ropivacaine dose of 115 +/- 29 mg. Cardiovascular side effects resulting from chloroprocaine administration should be treated with general supportive physiologic measures, such as oxygen therapy, assisted ventilation, and IV fluids.
During caudal or lumbar epidural block, unintentional penetration of the subarachnoid space may occur. Adverse effects depend upon the amount of drug given subdurally and may include spinal block of varying magnitude, hypotension secondary to spinal block, fecal or urinary incontinence, and loss of perineal sensation and sexual function. Arachnoiditis and persistent motor, sensory, and/or autonomic (sphincter control) deficit of lower spinal segments with slow (several months) or incomplete recovery has been reported rarely. Back pain and headache have been reported following these procedures. Unintentional subarachnoid injection of chloroprocaine in cervical and thoracic areas has resulted in respiratory depression and apnea. During clinical trials of intrathecally administered chloroprocaine, headache was reported in less than 2% of patients who received a single intrathecal dose of 50 mg. Other adverse reactions reported during postmarketing use include malaise and hot flashes.
During labor and obstetric delivery, local anesthetics can cause varying degrees of maternal, fetal, and neonatal toxicities. The potential for toxicity is related to the procedure performed, the type and amount of drug used, and the technique of administration. Fetal heart rate should be monitored continuously because fetal bradycardia may occur in patients receiving chloroprocaine anesthesia and may be associated with fetal acidosis. Maternal hypotension can result from regional anesthesia; patient position can alleviate this problem. The injection should be performed with the patient in the left lateral decubitus position to displace the gravid uterus, thereby minimizing aortocaval compression. Epidural chloroprocaine may cause decreased uterine contractility or maternal expulsion efforts and alter the forces of parturition.
Unintentional fetal intracranial injection of chloroprocaine has occurred during pudendal or paracervical block. Infants so affected often present with unexplained neonatal depression at birth and can develop seizures within 6 hours as a result of high serum concentrations. Hypotonia may occur in the neonate during the first 1-2 days of life following the use of local anesthetics during labor and delivery; long-term clinical effects are not known.
Allergic reactions including sneezing, rash, urticaria, pruritus, erythema, erythema multiforme, angioedema with possible airway obstruction, laryngeal edema, and anaphylactoid reactions have occurred in patients receiving local anesthetic agents, especially ester-type local anesthetics. Allergic-type reactions may also occur in response to methylparaben, which is an antimicrobial preservative contained in chloroprocaine multidose vials. Other symptoms observed during allergic reactions include sinus tachycardia, nausea, vomiting, dizziness, syncope, diaphoresis, and fever. Cross sensitivity with other ester-type local anesthetics has occurred.
Preexisting inflammation or infection increases the risk of developing serious skin side effects. Monitor patients for an injection site reaction. Injection site pain was reported in 3.7% of patients who received a single intrathecal dose of chloroprocaine 50 mg during clinical trials. Procedural pain was reported in 16% of patients who received a single intrathecal dose of chloroprocaine 50 mg during clinical trials. Delayed recovery from anesthesia, postoperative urinary retention, groin pain, and extremity pain have also been observed in postmarketing.
Local anesthetics such as chloroprocaine administered by a continuous infusion to a joint space may cause chondrolysis (necrosis and destruction of cartilage). The FDA has received 35 reports of chondrolysis in patients given continuous intra-articular infusions of local anesthetics with elastomeric infusion devices to control post-surgical pain. Data suggest that the reported cases of chondrolysis are not associated with any single manufacturer of elastomeric infusion devices. In all but 1 patient, chondrolysis occurred after shoulder surgeries. The local anesthetics +/- epinephrine were infused for 48 to 72 hours directly into the intra-articular space using an elastomeric pump. The most commonly reported site of infusion was the glenohumeral (glenoid) space (46%), and bupivacaine was at least 1 of the local anesthetics used in all 35 cases. Joint pain, stiffness, and loss of motion were reported as early as the second month after infusion receipt. Chondrolysis was diagnosed a median of 8.5 months after the infusion. In more than half of these reports, the patients required additional surgery including arthroscopy or arthroplasty. In addition to the 35 bupivacaine-related cases, the FDA has received four additional reports of chondrolysis in patients administered continuous intra-articular infusions of lidocaine in the shoulder. It is not known which specific factor or combination of factors contributed to the development of chondrolysis. Insufficient information exists to determine if shorter infusion periods (< 48 hours) are not associated with chondrolysis. The infused local anesthetic drugs, the device materials, and/or other sources may have resulted in the development of chondrolysis. In vitro data do suggest that bupivacaine, lidocaine, and ropivacaine cause chondrolysis. Local anesthetics are not indicated for continuous intra-articular postoperative infusions or for use with infusion devices such as elastomeric pumps. Health care professionals are advised to NOT use elastomeric infusion devices for continuous intra-articular infusion of local anesthetics after orthopedic surgery. Of importance, single intra-articular injections of local anesthetics in orthopedic procedures have been used for many years without any reported occurrence of chondrolysis. If a patient has received a continuous intra-articular postoperative infusion of a local anesthetic, monitor the patient for the emergence of the signs and symptoms of chondrolysis such as joint pain, stiffness, and loss of motion. Also, instruct the patient to report any such symptoms. The appearance of these symptoms can be variable and may begin two or more months after surgery.
Hyperglycemia was reported in less than 2% of patients who received a single intrathecal dose of chloroprocaine 50 mg during clinical trials.
Sensory adverse reactions observed during postmarketing use of parenteral chloroprocaine include diplopia, photophobia, blurred vision, visual disorders (unspecified), hearing impairment, tinnitus, and speech disorders. Mydriasis (26% chloroprocaine vs. 2% placebo), conjunctival hyperemia (11% vs. 12%), and ocular irritation (6% vs. 4%) were reported during placebo-controlled trials of chloroprocaine ophthalmic gel (n = 151 chloroprocaine; n = 50 placebo). Corneal opacification and ulceration with accompanying visual loss may occur with prolonged use of topical anesthetics. Due to eye insensitivity and risk of corneal injury, advise patients to avoid touching their eye for at least 10 to 20 minutes following use of ophthalmic chloroprocaine.
Methemoglobinemia has been reported with local anesthetic use. Signs and symptoms of methemoglobinemia may occur immediately or may be delayed some hours after local anesthetic exposure and are characterized by cyanotic skin discoloration and abnormal coloration of the blood. Other symptoms may include headache, rapid heart rate, shortness of breath, dizziness, and drowsiness. Since methemoglobin concentrations may continue to rise, immediately discontinue chloroprocaine to avoid serious central nervous system and cardiovascular adverse events including seizures, coma, arrhythmias, and death. Depending on the severity of symptoms, patients may require supportive care, such as oxygen therapy and hydration. More severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
The following ocular adverse reactions were reported at an incidence of greater than or equal to 5% with the chloroprocaine ophthalmic gel: mydriasis (26%), conjunctival hyperemia (11%), and ocular irritation (6%).
Local anesthetics should only be administered by a clinician trained in the diagnosis and management of drug-related toxicity and other acute emergencies that might arise from the administration of a regional anesthetic block. The immediate availability of oxygen, cardiopulmonary resuscitative equipment and drugs and the appropriate support personnel for the management of toxic reactions or emergencies must be ensured. Any delay in appropriate management may lead to the development of acidosis, cardiac arrest and possibly death.
Chloroprocaine is contraindicated in patients with known ester local anesthetic hypersensitivity or para-aminobenzoic acid, PABA hypersensitivity. Chloroprocaine is more likely to cause hypersensitivity reactions than are amide-type local anesthetics. Some formulations contain methylparaben and may be inappropriate for patients with paraben hypersensitivity. Also, formulations with methylparaben should not be used for lumbar or caudal epidural anesthesia because safety of this antimicrobial preservative has not been established in regard to inadvertent or intended intrathecal injection.
The use of chloroprocaine requires an experienced clinician knowledgeable in anesthetic technique and the management of dose-related toxicities. Intravenous administration or intraarterial administration of chloroprocaine should be avoided. Only the Clorotekal formulation of chloroprocaine is intended for intrathecal administration; other chloroprocaine products must not be given intrathecally. Clorotekal is contraindicated for use in intravenous regional anesthesia, and epidural administration should be avoided. Unintended intravenous or intraarterial administration may result in cardiac arrest and may require prolonged resuscitation. To avoid intravascular administration of chloroprocaine during local anesthetic procedures, aspiration should be performed before the local anesthetic is injected and after repositioning of the needle. During epidural administration, a test dose should be administered initially and the patient should be monitored for CNS and cardiovascular toxicity, as well as signs of inadvertent intrathecal administration. Syringe aspiration should also be performed before and during each supplemental injection in continuous catheter techniques. Clinicians should be aware that the absence of blood return does not guarantee that intravascular injection has been avoided. Chloroprocaine ophthalmic gel is not for injection or intraocular use.
During head and neck anesthesia, including dental and ophthalmic anesthesia, small doses of local anesthetics may produce adverse reactions similar to the systemic toxicity seen with unintentional intravascular injections of larger doses. Patients receiving local head and neck anesthesia are at increased risk of CNS toxicity due to potential intraarterial injection of the local anesthetic with retrograde flow to the cerebral circulation. Patients receiving these blocks should have their ventilatory and circulatory systems monitored closely. Recommended doses should not be exceeded in these patients.
When local anesthetics are used for retrobulbar block during ocular surgery, lack of corneal sensation should not be relied upon to determine whether or not the patient is ready for surgery. Lack of corneal sensation usually precedes clinically acceptable external ocular muscle akinesia.
Intrathecal chloroprocaine is contraindicated in patients with coagulopathy, local infection at the injection site, or sepsis. Use lumbar and caudal epidural anesthesia with extreme caution in patients with neurological disease, spinal deformities, sepsis, or severe hypertension.
Intrathecal chloroprocaine is specifically contraindicated for use in patients with decompensated cardiac insufficiency, hypovolemic shock, and other serious problems with cardiac conduction. Local anesthetics should be used with caution in patients with hypotension, hypovolemia or dehydration, myasthenia gravis, shock, or cardiac disease. Patients with impaired cardiac function, particularly AV block, may be less able to compensate for functional changes associated with prolonged A-V conduction (i.e., PR or QT prolongation) caused by local anesthetics.
Geriatric patients, especially those receiving treatment for hypertension, may be at increased risk for the hypotensive effects of local anesthetics. Monitor blood pressure carefully.
Ester-type local anesthetics should be used cautiously, if at all, in patients with low plasma concentrations of pseudocholinesterase (e.g., pseudocholinesterase deficiency). Ester-type local anesthetics are metabolized by hydrolysis by pseudocholinesterase.
Use chloroprocaine with caution in patients with advanced hepatic disease. Ester-type anesthetics are hydrolyzed by plasma cholinesterase produced by the liver, and the risk of toxic effects may be greater in patients with advanced hepatic disease.
Chloroprocaine and its metabolites undergo substantial renal elimination, and the risk of toxic effects may be greater in patients with renal impairment or renal failure.
The limited data with chloroprocaine use in pregnancy are insufficient to inform a drug associated risk of adverse developmental outcomes. Placental transfer of local anesthetics is dependent upon the degree of plasma protein binding, ionization, and lipid solubility of each agent. No intact chloroprocaine and only trace amounts of its byproduct have been found in umbilical cord arterial or venous plasma after properly administered paracervical blocks. Local anesthetics used as epidural, paracervical, caudal, or pudendal nerve block anesthesia for obstetric delivery can cause maternal, fetal, or neonatal toxicity. The incidence and severity of toxicity depend upon the procedure performed, the type and amount of drug used, and drug administration technique. Proper positioning of the patient will help to decrease maternal hypotension occurring secondary to anesthetic-induced vasodilation. Injection of the local anesthetic should be performed with the patient in the left lateral decubitus position to displace the gravid uterus, thereby minimizing aortocaval compression. Epidural, caudal, paracervical, or pudendal nerve block may alter the forces of parturition. The use of obstetrical anesthesia may alter the duration of various phases of labor and increase the need for forceps assistance. Paracervical nerve block may be associated with a decrease in the mean duration of first stage labor and facilitation of cervical dilation. Epidural or spinal anesthesia may prolong the second stage of labor by removing the reflex urge to bear down or by interfering with motor function. Fetal bradycardia has occurred during use of paracervical block anesthesia in about 5% to 10% of cases where initial total doses of 120 to 400 mg of chloroprocaine were administered. Fetal heart rate should always be monitored during paracervical anesthesia. Use of obstetrical paracervical block with chloroprocaine in the presence of eclampsia, fetal distress, or fetal prematurity is not recommended. In general, local anesthetics should be used with extreme caution in patients with pregnancies complicated by fetal prematurity, eclampsia, fetal distress, or maternal or fetal sepsis. Electronic fetal monitoring for signs of fetal distress is highly recommended. Use of paracervical block in early pregnancy (i.e., anesthesia for elective abortion) may result in rapid systemic absorption and can result in maternal seizures or cardiovascular collapse. Injections should be administered slowly with frequent aspirations. Allow a 5-minute interval between chloroprocaine administration to each side. When used during labor and delivery, some local anesthetics have been associated with diminished muscle strength and tone in the newborn for the first day or 2 of life. There are no adequate and well-controlled studies of topical ophthalmic administration of chloroprocaine ophthalmic gel in human pregnancy. Animal reproduction studies have not been conducted with chloroprocaine ophthalmic gel.
There are no data describing the presence of chloroprocaine in human milk, the effects on the breast-fed infant, or the effects on milk production. Consider the developmental and health benefits of breast-feeding along with the mother's clinical need for chloroprocaine and any potential adverse effects on the breast-fed infant from chloroprocaine or the underlying maternal condition. Other local anesthetics, such as lidocaine and bupivacaine, are minimally excreted into breast milk; however, the potential for adverse effects in the nursing infant is low due to poor oral absorption. Although chloroprocaine was not evaluated by the American Academy of Pediatrics (AAP), previous AAP recommendations considered lidocaine to be usually compatible with breast-feeding.
Methemoglobinemia has been reported with local anesthetic use. Although all patients are at risk for methemoglobinemia, patients with glucose-6-phosphate dehydrogenase deficiency (G6PD deficiency), preexisting (congenital or idiopathic) methemoglobinemia, cardiac or pulmonary compromise (cardiac disease or pulmonary disease), neonates and infants younger than 6 months, and those with concurrent exposure to oxidizing agents or their metabolites are more susceptible to developing methemoglobinemia. Monitor such patients closely for signs and symptoms of methemoglobinemia if a local anesthetic must be used. Signs of methemoglobinemia may occur immediately or may be delayed hours after exposure. Immediately discontinue the local anesthetic to avoid serious central nervous system and cardiovascular adverse events, as methemoglobin concentrations may continue to rise. Patients may require supportive care such as oxygen therapy and hydration. More severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Chloroprocaine ophthalmic gel is not intended for patient self-administration, and must be administered under the direct supervision of a health care provider. After ocular use, the eye may be inadvertently damaged while anesthetic effects remain. Patients should avoid touching, rubbing, or wiping the eyes for at least 10 to 20 minutes. Contact lenses should not be inserted until the anesthetic effects of chloroprocaine have completely waned. Prolonged use may result in permanent corneal opacification and ulceration with accompanying visual loss.
For regional anesthesia:
NOTE: Doses listed below are those considered necessary to produce a successful block and should be regarded as guidelines. Individual variations in onset and duration may occur.
-for epidural anesthesia:
Epidural dosage for the cervical or thoracic region:
Adults: 1.5 to 2 mL of a 2% or 3% solution (30 to 60 mg) epidurally for each segment to be anesthetized.
Epidural dosage for the lumbar and sacral region:
Adults: 2 to 2.5 mL of a 2% or 3% solution epidurally for each segment to be anesthetized. Repeat doses of 2 to 6 mL less than the original dose may be given at 40 to 50 minute intervals.
-for caudal anesthesia:
Epidural dosage:
Adults: 15 to 25 mL of a 2% or 3% solution (300 to 750 mg) epidurally. Repeat doses may be given at 40 to 60 minute intervals.
-for spinal anesthesia (Clorotekal):
Intrathecal dosage:
Adults: 50 mg intrathecally once to obtain an effective block to the T10 level for an adult with average height and weight (approximately 70 kg). The safety and efficacy of doses above 50 mg have not been established.
For local anesthesia via infiltration anesthesia or nerve block anesthesia:
NOTE: Doses listed below are those considered necessary to produce a successful block and should be regarded as guidelines. Individual variations in onset and duration may occur.
-Occipital nerve block:
Regional dosage:
Adults: 3 to 5 mL of a 1% to 2% solution (30 to 100 mg).
-Mandibular nerve block or maxillary nerve block for dental anesthesia:
Regional dosage:
Adults: 2 to 3 mL of a 2% solution (40 to 60 mg).
-Infraorbital nerve block:
Regional dosage:
Adults: 0.5 to 1 mL of a 2% solution (10 to 20 mg).
-Cervical nerve block:
Regional dosage:
Adults: 3 to 4 mL of a 1% to 2% solution (30 to 80 mg) per segment.
-Brachial plexus block:
Regional dosage:
Adults: 30 to 40 mL of a 2% solution (600 to 800 mg).
-Ulnar nerve block or paravertebral block:
Regional dosage:
Adults: 3 to 5 mL of a 2% solution (60 to 100 mg).
-Intercostal nerve block:
Regional dosage:
Adults: 3 mL of a 1% to 2% solution (30 to 60 mg).
-Sciatic nerve block:
Regional dosage:
Adults: 10 to 15 mL of a 2% solution (200 to 300 mg).
-Stellate ganglion block:
Regional dosage:
Adults: 5 to 10 mL of a 1% to 2% solution (50 to 200 mg).
-Lumbar sympathetic block:
Regional dosage:
Adults: 15 to 20 mL of a 1% to 2% solution (150 to 400 mg).
-Interdigital block:
Regional dosage:
Adults: 3 to 4 mL of a 1% solution without epinephrine (30 to 40 mg).
For use in obstetric anesthesia:
-pudendal nerve block:
Regional dosage:
Adults: 10 mL of a 2% solution (200 mg) for each side.
-paracervical block:
Regional dosage:
Adults: 3 mL of a 1% solution (30 mg) for each of 4 sites up to 120 mg.
For ophthalmic anesthesia:
Ophthalmic dosage (Iheezo 3%):
Adults: 3 drops applied to the ocular surface in the area of the planned procedure. Reapply as needed to maintain therapeutic effect.
Maximum Dosage Limits:
The dose of local anesthetics differs with the anesthetic procedure; the area to be anesthetized; the vascularity of the tissues; the number of neuronal segments to be blocked; the intensity of the block; the degree of muscle relaxation required; the duration of anesthesia desired; individual tolerance; and the physical condition of the patient.
-Adults
50 mg/dose intrathecally; 11 mg/kg for other parenteral routes, not to exceed 800 mg/dose when given without epinephrine. With epinephrine (1:200,000), 14 mg/kg, not to exceed 1,000 mg. 3 drops/dose for ophthalmic gel.
-Geriatric
50 mg/dose intrathecally. 11 mg/kg for other parenteral routes, not to exceed 800 mg/dose when given without epinephrine. With epinephrine (1:200,000), 14 mg/kg, not to exceed 1,000 mg. 3 drops/dose for ophthalmic gel.
-Adolescents
11 mg/kg. Concentrations of 0.5% to 1% are suggested for infiltration, and 1% to 1.5% are recommended for nerve block. Safety and efficacy of the ophthalmic gel and intrathecal chloroprocaine have not been established.
-Children
4 years and older: 11 mg/kg. Concentrations of 0.5% to 1% are suggested for infiltration, and 1% to 1.5% are recommended for nerve block. Safety and efficacy of the ophthalmic gel and intrathecal chloroprocaine have not been established.
3 years and younger: Safety and efficacy have not been established.
-Infants
Safety and efficacy have not been established.
-Neonates
Safety and efficacy have not been established.
Patients with Hepatic Impairment Dosing
Use with caution in patients with advanced hepatic disease. Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.
Patients with Renal Impairment Dosing
Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.
*non-FDA-approved indication
Acebutolol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Acetaminophen: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Aspirin, ASA; Caffeine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Aspirin: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Aspirin; Diphenhydramine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Caffeine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Caffeine; Dihydrocodeine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen. (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Acetaminophen; Caffeine; Pyrilamine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Chlorpheniramine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Chlorpheniramine; Dextromethorphan: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Chlorpheniramine; Dextromethorphan; Phenylephrine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Chlorpheniramine; Dextromethorphan; Pseudoephedrine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Chlorpheniramine; Phenylephrine : (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Codeine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen. (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Acetaminophen; Dextromethorphan: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Dextromethorphan; Doxylamine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Dextromethorphan; Guaifenesin; Phenylephrine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Dextromethorphan; Guaifenesin; Pseudoephedrine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Dextromethorphan; Phenylephrine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Dextromethorphan; Pseudoephedrine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Diphenhydramine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Guaifenesin; Phenylephrine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Hydrocodone: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen. (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Acetaminophen; Ibuprofen: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Oxycodone: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen. (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Acetaminophen; Pamabrom; Pyrilamine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Phenylephrine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Acetaminophen; Pseudoephedrine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Alfentanil: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Alfuzosin: (Major) Alfuzosin has a slight effect to prolong the QT interval, and should be used cautiously in combination with other medications known to prolong the QT interval, such as local anesthetics.
Aliskiren; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Amiloride: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Amiloride; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Aminosalicylate sodium, Aminosalicylic acid: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as aminosalicylic acid, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Amlodipine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Amlodipine; Atorvastatin: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Amlodipine; Benazepril: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Amlodipine; Celecoxib: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Amlodipine; Olmesartan: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Amlodipine; Valsartan: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Angiotensin II receptor antagonists: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Angiotensin-converting enzyme inhibitors: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Articaine; Epinephrine: (Moderate) Use articaine and chloroprocaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Aspirin, ASA; Caffeine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Aspirin, ASA; Carisoprodol; Codeine: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Aspirin, ASA; Oxycodone: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Atenolol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Atenolol; Chlorthalidone: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Atracurium: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Azilsartan: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Azilsartan; Chlorthalidone: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Belladonna; Opium: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Benazepril: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Benazepril; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Benzalkonium Chloride; Benzocaine: (Moderate) Use chloroprocaine and benzocaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Benzhydrocodone; Acetaminophen: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Benzocaine: (Moderate) Use chloroprocaine and benzocaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Benzocaine; Butamben; Tetracaine: (Moderate) Use chloroprocaine and benzocaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Beta-adrenergic blockers: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Betaxolol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Bisoprolol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Bisoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Brimonidine; Timolol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Bumetanide: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Bupivacaine Liposomal: (Major) Avoid use of other local anesthetics for 96 hours after liposomal bupivacaine administration. Use chloroprocaine and other formulations of bupivacaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Bupivacaine: (Major) Avoid use of other local anesthetics for 96 hours after liposomal bupivacaine administration. Use chloroprocaine and other formulations of bupivacaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Bupivacaine; Epinephrine: (Major) Avoid use of other local anesthetics for 96 hours after liposomal bupivacaine administration. Use chloroprocaine and other formulations of bupivacaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Bupivacaine; Lidocaine: (Major) Avoid use of other local anesthetics for 96 hours after liposomal bupivacaine administration. Use chloroprocaine and other formulations of bupivacaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen. (Moderate) Use lidocaine and chloroprocaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Bupivacaine; Meloxicam: (Major) Avoid use of other local anesthetics for 96 hours after liposomal bupivacaine administration. Use chloroprocaine and other formulations of bupivacaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Butalbital; Acetaminophen: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Butalbital; Acetaminophen; Caffeine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Butalbital; Acetaminophen; Caffeine; Codeine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen. (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Butalbital; Aspirin; Caffeine; Codeine: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Calcium-channel blockers: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Candesartan: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Candesartan; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Captopril: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Captopril; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Carteolol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Carvedilol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Central-acting adrenergic agents: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Chloroquine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as chloroquine, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Chlorothiazide: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Chlorpheniramine; Codeine: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Chlorpheniramine; Hydrocodone: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Chlorthalidone: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Cholinesterase inhibitors: (Moderate) Local anesthetics can antagonize the effects of cholinesterase inhibitors by inhibiting neuronal transmission in skeletal muscle, especially if large doses of local anesthetics are used. Also, local anesthetics interfere with the release of acetylcholine. Dosage adjustment of the cholinesterase inhibitor may be necessary.
Cisatracurium: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Clevidipine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Clonidine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Codeine: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Codeine; Guaifenesin: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Codeine; Guaifenesin; Pseudoephedrine: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Codeine; Phenylephrine; Promethazine: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Codeine; Promethazine: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Cyclophosphamide: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as cyclophosphamide, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Dapsone: (Moderate) Coadministration of dapsone with chloroprocaine may increase the risk of developing methemoglobinemia. Advise patients to discontinue treatment and seek immediate medical attention with any signs or symptoms of methemoglobinemia.
Daratumumab; Hyaluronidase: (Moderate) Hyaluronidase, when used in combination with local anesthetics, hastens the onset of analgesia and reduces the swelling caused by local infiltration; this interaction is beneficial and is the reason hyaluronidase is used adjunctively in local infiltrative anesthesia techniques. However, the wider spread of the local anesthetic solution may increase the systemic absorption of the local anesthetic, which shortens the duration of anesthetic action and tends to increase the potential risk for systemic side effects.
Diazoxide: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Diltiazem: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Donepezil: (Moderate) Local anesthetics can antagonize the effects of cholinesterase inhibitors by inhibiting neuronal transmission in skeletal muscle, especially if large doses of local anesthetics are used. Also, local anesthetics interfere with the release of acetylcholine. Dosage adjustment of the cholinesterase inhibitor may be necessary.
Donepezil; Memantine: (Moderate) Local anesthetics can antagonize the effects of cholinesterase inhibitors by inhibiting neuronal transmission in skeletal muscle, especially if large doses of local anesthetics are used. Also, local anesthetics interfere with the release of acetylcholine. Dosage adjustment of the cholinesterase inhibitor may be necessary.
Dorzolamide; Timolol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Efgartigimod Alfa; Hyaluronidase: (Moderate) Hyaluronidase, when used in combination with local anesthetics, hastens the onset of analgesia and reduces the swelling caused by local infiltration; this interaction is beneficial and is the reason hyaluronidase is used adjunctively in local infiltrative anesthesia techniques. However, the wider spread of the local anesthetic solution may increase the systemic absorption of the local anesthetic, which shortens the duration of anesthetic action and tends to increase the potential risk for systemic side effects.
Enalapril, Enalaprilat: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Enalapril; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Eplerenone: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Eprosartan: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Eprosartan; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Esmolol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Ethacrynic Acid: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Etomidate: (Major) Due to the cardiotoxic potential of all local anesthetics, they should be used with caution with other agents that can prolong the QT interval, such as general anesthetics. If epinephrine is added to chloroprocaine, do not use the mixture in a patient during or following treatment with general anesthetics.
Felodipine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Fenoldopam: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Fentanyl: (Moderate) The use of these drugs together must be approached with caution. Although commonly used together for additive analgesic effects, the patient must be monitored for respiratory depression, hypotension, and excessive sedation due to additive effects on the CNS and blood pressure. In rare instances, serious morbidity and mortality has occurred. Limit the use of opiate pain medications with local anesthetics to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect. The use of the local anesthetic will allow for the use a lower initial dose of the opiate and then the doses can be titrated to proper clinical response. Educate patients about the risks and symptoms of respiratory depression and sedation.
Flutamide: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as flutamide, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Fosinopril: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Fosinopril; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Fosphenytoin: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as fosphenytoin, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Furosemide: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Galantamine: (Moderate) Local anesthetics can antagonize the effects of cholinesterase inhibitors by inhibiting neuronal transmission in skeletal muscle, especially if large doses of local anesthetics are used. Also, local anesthetics interfere with the release of acetylcholine. Dosage adjustment of the cholinesterase inhibitor may be necessary.
General anesthetics: (Major) Due to the cardiotoxic potential of all local anesthetics, they should be used with caution with other agents that can prolong the QT interval, such as general anesthetics. If epinephrine is added to chloroprocaine, do not use the mixture in a patient during or following treatment with general anesthetics.
Guanfacine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Homatropine; Hydrocodone: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Hyaluronidase, Recombinant; Immune Globulin: (Moderate) Hyaluronidase, when used in combination with local anesthetics, hastens the onset of analgesia and reduces the swelling caused by local infiltration; this interaction is beneficial and is the reason hyaluronidase is used adjunctively in local infiltrative anesthesia techniques. However, the wider spread of the local anesthetic solution may increase the systemic absorption of the local anesthetic, which shortens the duration of anesthetic action and tends to increase the potential risk for systemic side effects.
Hyaluronidase: (Moderate) Hyaluronidase, when used in combination with local anesthetics, hastens the onset of analgesia and reduces the swelling caused by local infiltration; this interaction is beneficial and is the reason hyaluronidase is used adjunctively in local infiltrative anesthesia techniques. However, the wider spread of the local anesthetic solution may increase the systemic absorption of the local anesthetic, which shortens the duration of anesthetic action and tends to increase the potential risk for systemic side effects.
Hydralazine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Hydralazine; Isosorbide Dinitrate, ISDN: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as nitrates, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Hydrochlorothiazide, HCTZ; Moexipril: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Hydrocodone: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Hydrocodone; Ibuprofen: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Hydromorphone: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Hydroxyurea: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as hydroxyurea, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Ibuprofen; Oxycodone: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Ifosfamide: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as ifosfamide, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Iloprost: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Irbesartan: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Irbesartan; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Isocarboxazid: (Major) Combined hypotensive effects are possible with use of monoamine oxidase inhibitors (MAOIs) and spinal anesthetics. When local anesthetics containing sympathomimetic vasoconstrictors are coadministered with MAOIs, severe and prolonged hypertension may occur. MAOIs can increase the sensitivity to epinephrine by inhibiting epinephrine reuptake or metabolism. If concurrent therapy is necessary, carefully monitor the patient. Phenelzine and tranylcypromine are contraindicated for use for at least 10 days prior to elective surgery.
Isoflurane: (Major) Due to the cardiotoxic potential of all local anesthetics, they should be used with caution with other agents that can prolong the QT interval, such as general anesthetics. If epinephrine is added to chloroprocaine, do not use the mixture in a patient during or following treatment with general anesthetics.
Isosorbide Dinitrate, ISDN: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as nitrates, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Isosorbide Mononitrate: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as nitrates, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Isradipine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Ketamine: (Major) Due to the cardiotoxic potential of all local anesthetics, they should be used with caution with other agents that can prolong the QT interval, such as general anesthetics. If epinephrine is added to chloroprocaine, do not use the mixture in a patient during or following treatment with general anesthetics.
Labetalol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Lamotrigine: (Moderate) Consider ECG monitoring before and during concomitant use of lamotrigine with other sodium channel blockers known to impair atrioventricular and/or intraventricular cardiac conduction, such as chloroprocaine. Concomitant use of chloroprocaine with lamotrigine may increase the risk of proarrhythmia, especially in patients with clinically important structural or functional heart disease. In vitro testing showed that lamotrigine exhibits class IB antiarrhythmic activity at therapeutically relevant concentrations.
Levamlodipine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Levobunolol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Levorphanol: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Lidocaine: (Moderate) Use lidocaine and chloroprocaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Lidocaine; Epinephrine: (Moderate) Use lidocaine and chloroprocaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Lidocaine; Prilocaine: (Moderate) Use lidocaine and chloroprocaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen. (Moderate) Use prilocaine and chloroprocaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Lisinopril: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Lisinopril; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Loop diuretics: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Losartan: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Losartan; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Mafenide: (Major) Coadministration of chloroprocaine with sulfonamides may antagonize the effect of sulfonamides. Chloroprocaine is metabolized to para-aminobenzoic acid (PABA). PABA antagonized the effects of sulfonamides. Additionally, coadministration of chloroprocaine with oxidizing agents, such as sulfonamides, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Mecamylamine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Meperidine: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Mepivacaine: (Moderate) Use mepivacaine and chloroprocaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Methohexital: (Major) If epinephrine is added to chloroprocaine, do not use the mixture in a patient during or following treatment with general anesthetics. Concurrent use has been associated with the development of cardiac arrhythmias, and should be avoided, if possible.
Methyldopa: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Metoclopramide: (Moderate) Coadministration of chloroprocaine with metoclopramide may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other agents associated with methemoglobinemia. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Metolazone: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Metoprolol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Metoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Minocycline: (Moderate) Injectable minocycline contains magnesium sulfate heptahydrate. Because of the CNS-depressant effects of magnesium sulfate, additive central-depressant effects can occur following concurrent administration with CNS depressants such as local anesthetics. Caution should be exercised when using these agents concurrently.
Minoxidil: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Moexipril: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Monoamine oxidase inhibitors: (Major) Combined hypotensive effects are possible with use of monoamine oxidase inhibitors (MAOIs) and spinal anesthetics. When local anesthetics containing sympathomimetic vasoconstrictors are coadministered with MAOIs, severe and prolonged hypertension may occur. MAOIs can increase the sensitivity to epinephrine by inhibiting epinephrine reuptake or metabolism. If concurrent therapy is necessary, carefully monitor the patient. Phenelzine and tranylcypromine are contraindicated for use for at least 10 days prior to elective surgery.
Nadolol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Nebivolol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Nebivolol; Valsartan: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Neostigmine: (Moderate) Local anesthetics can antagonize the effects of cholinesterase inhibitors by inhibiting neuronal transmission in skeletal muscle, especially if large doses of local anesthetics are used. Also, local anesthetics interfere with the release of acetylcholine. Dosage adjustment of the cholinesterase inhibitor may be necessary.
Neostigmine; Glycopyrrolate: (Moderate) Local anesthetics can antagonize the effects of cholinesterase inhibitors by inhibiting neuronal transmission in skeletal muscle, especially if large doses of local anesthetics are used. Also, local anesthetics interfere with the release of acetylcholine. Dosage adjustment of the cholinesterase inhibitor may be necessary.
Neuromuscular blockers: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Nicardipine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
NIFEdipine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Nimodipine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Nisoldipine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Nitrates: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as nitrates, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Nitrofurantoin: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as nitrofurantoin, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Nitroglycerin: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as nitrates, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Nitroprusside: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Olmesartan: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Olmesartan; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Oxycodone: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Oxymorphone: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Pancuronium: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Perindopril: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Perindopril; Amlodipine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Pertuzumab; Trastuzumab; Hyaluronidase: (Moderate) Hyaluronidase, when used in combination with local anesthetics, hastens the onset of analgesia and reduces the swelling caused by local infiltration; this interaction is beneficial and is the reason hyaluronidase is used adjunctively in local infiltrative anesthesia techniques. However, the wider spread of the local anesthetic solution may increase the systemic absorption of the local anesthetic, which shortens the duration of anesthetic action and tends to increase the potential risk for systemic side effects.
Phenelzine: (Major) Combined hypotensive effects are possible with use of monoamine oxidase inhibitors (MAOIs) and spinal anesthetics. When local anesthetics containing sympathomimetic vasoconstrictors are coadministered with MAOIs, severe and prolonged hypertension may occur. MAOIs can increase the sensitivity to epinephrine by inhibiting epinephrine reuptake or metabolism. If concurrent therapy is necessary, carefully monitor the patient. Phenelzine and tranylcypromine are contraindicated for use for at least 10 days prior to elective surgery.
Phenobarbital: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as phenobarbital, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Phenobarbital; Hyoscyamine; Atropine; Scopolamine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as phenobarbital, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Phenytoin: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as phenytoin, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Physostigmine: (Moderate) Local anesthetics can antagonize the effects of cholinesterase inhibitors by inhibiting neuronal transmission in skeletal muscle, especially if large doses of local anesthetics are used. Also, local anesthetics interfere with the release of acetylcholine. Dosage adjustment of the cholinesterase inhibitor may be necessary.
Pindolol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Potassium-sparing diuretics: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Prilocaine: (Moderate) Use prilocaine and chloroprocaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Prilocaine; Epinephrine: (Moderate) Use prilocaine and chloroprocaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Primaquine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as primaquine, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Primidone: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as primidone, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Procarbazine: (Major) Patients taking procarbazine should not be given local anesthetics containing sympathomimetic vasoconstrictors; coadministration may invoke a severe hypertensive reaction. Procarbazine should be discontinued for at least 10 days prior to elective surgery.
Propofol: (Major) Due to the cardiotoxic potential of all local anesthetics, they should be used with caution with other agents that can prolong the QT interval, such as general anesthetics. If epinephrine is added to chloroprocaine, do not use the mixture in a patient during or following treatment with general anesthetics.
Propranolol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Pyridostigmine: (Moderate) Local anesthetics can antagonize the effects of cholinesterase inhibitors by inhibiting neuronal transmission in skeletal muscle, especially if large doses of local anesthetics are used. Also, local anesthetics interfere with the release of acetylcholine. Dosage adjustment of the cholinesterase inhibitor may be necessary.
Quinapril: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Quinapril; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Quinine: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as quinine, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Ramipril: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Rasburicase: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as rasburicase, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Remifentanil: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Rituximab; Hyaluronidase: (Moderate) Hyaluronidase, when used in combination with local anesthetics, hastens the onset of analgesia and reduces the swelling caused by local infiltration; this interaction is beneficial and is the reason hyaluronidase is used adjunctively in local infiltrative anesthesia techniques. However, the wider spread of the local anesthetic solution may increase the systemic absorption of the local anesthetic, which shortens the duration of anesthetic action and tends to increase the potential risk for systemic side effects.
Rivastigmine: (Moderate) Local anesthetics can antagonize the effects of cholinesterase inhibitors by inhibiting neuronal transmission in skeletal muscle, especially if large doses of local anesthetics are used. Also, local anesthetics interfere with the release of acetylcholine. Dosage adjustment of the cholinesterase inhibitor may be necessary.
Rocuronium: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Ropivacaine: (Moderate) Use ropivacaine and chloroprocaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Sacubitril; Valsartan: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Sevoflurane: (Major) Due to the cardiotoxic potential of all local anesthetics, they should be used with caution with other agents that can prolong the QT interval, such as general anesthetics. If epinephrine is added to chloroprocaine, do not use the mixture in a patient during or following treatment with general anesthetics.
Spironolactone: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Spironolactone; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Succinylcholine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Sufentanil: (Minor) Due to the CNS depression potential of all local anesthetics, they should be used with caution with other agents that can cause respiratory depression, such as opiate agonists.
Sulfadiazine: (Major) Coadministration of chloroprocaine with sulfonamides may antagonize the effect of sulfonamides. Chloroprocaine is metabolized to para-aminobenzoic acid (PABA). PABA antagonized the effects of sulfonamides. Additionally, coadministration of chloroprocaine with oxidizing agents, such as sulfonamides, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Sulfamethoxazole; Trimethoprim, SMX-TMP, Cotrimoxazole: (Major) Coadministration of chloroprocaine with sulfonamides may antagonize the effect of sulfonamides. Chloroprocaine is metabolized to para-aminobenzoic acid (PABA). PABA antagonized the effects of sulfonamides. Additionally, coadministration of chloroprocaine with oxidizing agents, such as sulfonamides, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Sulfasalazine: (Major) Coadministration of chloroprocaine with sulfonamides may antagonize the effect of sulfonamides. Chloroprocaine is metabolized to para-aminobenzoic acid (PABA). PABA antagonized the effects of sulfonamides. Additionally, coadministration of chloroprocaine with oxidizing agents, such as sulfonamides, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Sulfonamides: (Major) Coadministration of chloroprocaine with sulfonamides may antagonize the effect of sulfonamides. Chloroprocaine is metabolized to para-aminobenzoic acid (PABA). PABA antagonized the effects of sulfonamides. Additionally, coadministration of chloroprocaine with oxidizing agents, such as sulfonamides, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Telmisartan: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Telmisartan; Amlodipine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Telmisartan; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Tetracaine: (Moderate) Use tetracaine and chloroprocaine together with caution. Monitor cardiovascular and respiratory vital signs, as well as the patient's state of consciousness if used concurrently due to potential for additive CNS and/or cardiovascular toxic effects. Manifestations of toxicity may include CNS excitation and/or depression, cardiac conduction depression, or peripheral vasodilation. Additionally, coadministration may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue local anesthetic use. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Thiazide diuretics: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Timolol: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Torsemide: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Tramadol; Acetaminophen: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as acetaminophen, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Trandolapril: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Trandolapril; Verapamil: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Tranylcypromine: (Major) Combined hypotensive effects are possible with use of monoamine oxidase inhibitors (MAOIs) and spinal anesthetics. When local anesthetics containing sympathomimetic vasoconstrictors are coadministered with MAOIs, severe and prolonged hypertension may occur. MAOIs can increase the sensitivity to epinephrine by inhibiting epinephrine reuptake or metabolism. If concurrent therapy is necessary, carefully monitor the patient. Phenelzine and tranylcypromine are contraindicated for use for at least 10 days prior to elective surgery.
Trastuzumab; Hyaluronidase: (Moderate) Hyaluronidase, when used in combination with local anesthetics, hastens the onset of analgesia and reduces the swelling caused by local infiltration; this interaction is beneficial and is the reason hyaluronidase is used adjunctively in local infiltrative anesthesia techniques. However, the wider spread of the local anesthetic solution may increase the systemic absorption of the local anesthetic, which shortens the duration of anesthetic action and tends to increase the potential risk for systemic side effects.
Treprostinil: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Triamterene: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Triamterene; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Valproic Acid, Divalproex Sodium: (Moderate) Coadministration of chloroprocaine with oxidizing agents, such as valproic acid, may increase the risk of developing methemoglobinemia. Monitor patients closely for signs and symptoms of methemoglobinemia if coadministration is necessary. If methemoglobinemia occurs or is suspected, discontinue chloroprocaine and any other oxidizing agents. Depending on the severity of symptoms, patients may respond to supportive care; more severe symptoms may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Valsartan: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Vasodilators: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Vecuronium: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Verapamil: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents.
Like all local anesthetics, chloroprocaine causes a reversible nerve-conduction blockade by decreasing nerve membrane permeability to sodium. This decreases the rate of membrane depolarization, thereby increasing the threshold for electrical excitability. The blockade affects all nerve fibers in the following sequence: autonomic, sensory, and motor, with effects diminishing in reverse order. Loss of nerve function clinically is as follows: pain, temperature, touch, proprioception, and skeletal muscle tone. Direct nerve membrane penetration is necessary for effective anesthesia, which is achieved by injecting the local anesthetic solution subcutaneously, intradermally, or submucosally around the nerve trunks or ganglia supplying the area to be anesthetized.
Systemic absorption of local anesthetics can produce effects on the central nervous and cardiovascular systems. At blood concentrations achieved with therapeutic doses, changes in cardiac conduction, excitability, refractoriness, contractility, and peripheral vascular resistance have been reported. Toxic blood concentrations depress cardiac conduction and excitability, which may lead to AV block, ventricular arrhythmia, and cardiac arrest, sometimes resulting in fatalities. In addition, myocardial contractility is depressed and peripheral vasodilation occurs, leading to decreased cardiac output and arterial blood pressure. Local anesthetics can produce central nervous system stimulation, depression, or both following systemic absorption. CNS stimulation is usually manifested as restlessness, tremors, and shivering progressing to convulsions, followed by depression and coma, progressing ultimately to respiratory arrest. However, local anesthetics have a primary depressant effect on the medulla and higher centers. The depressed stage may occur without the prior excitatory stage.
Chloroprocaine is administered parenterally via infiltration or nerve block, epidurally, intrathecally, or ophthalmically. Chloroprocaine is distributed to all body tissues, with a high concentration in well-perfused organs such as the liver, lungs, heart, and brain. Chloroprocaine is hydrolyzed by plasma pseudocholinesterases and nonspecific esterases in ocular tissues. Hydrolysis results in the formation of beta-diethylaminoethanol and 2-chloro-4-aminobenzoic acid. It is renally excreted and has an in vitro plasma half-life of 19 to 26 seconds in adults. The apparent half-life in vivo was 3.1 +/- 1.6 minutes (range 1.5 to 6.4 minutes) in maternal plasma following intrapartum epidural anesthesia.
Affected cytochrome P450 isoenzymes and/or drug transporters: none
-Route-Specific Pharmacokinetics
Other Route(s)
Epidural and Regional Routes
The absorption of chloroprocaine depends on the dose, concentration, route of administration, tissue vascularity, and degree of vasodilation. A vasoconstrictor, such as epinephrine, may be necessary to counteract the vasodilation produced by chloroprocaine. Epinephrine will slow the rate of absorption, prolong the duration of action, and maintain hemostasis. Anesthesia is obtained within 6 to 12 minutes and lasts approximately 30 to 60 minutes (60 to 90 minutes if epinephrine 1:200,000 is used).
Ophthalmic Route
Systemic exposure to chloroprocaine following topical administration to the ocular surface has not been studied.
-Special Populations
Pediatrics
The plasma half-life of chloroprocaine is 41 to 45 seconds in neonates.