Pharmacokinetics of lidocaine with epinephrine following local anesthesia reversal with phentolamine mesylate

Abstract

Phentolamine mesylate accelerates recovery from oral soft tissue anesthesia in patients who have received local anesthetic injections containing a vasoconstrictor. The proposed mechanism is that phentolamine, an alpha-adrenergic antagonist, blocks the vasoconstriction associated with the epinephrine used in dental anesthetic formulations, thus enhancing the systemic absorption of the local anesthetic from the injection site. Assessments of the pharmacokinetics of lidocaine and phentolamine, and the impact of phentolamine on the pharmacokinetics of lidocaine with epinephrine were performed to characterize this potentially valuable strategy. The blood levels of phentolamine were determined following its administration intraorally and intravenously. Additionally, the effects of phentolamine mesylate on the pharmacokinetics of intraoral injections of lidocaine with epinephrine were evaluated. Sixteen subjects were enrolled in this phase 1 trial, each receiving 4 drug treatments: 1 cartridge lidocaine/epinephrine followed after 30 minutes by 1 cartridge phentolamine (1L1P), 1 cartridge phentolamine administered intravenously (1Piv), 4 cartridges lidocaine/epinephrine followed after 30 minutes by 2 cartridges phentolamine (4L2P), and 4 cartridges lidocaine/epinephrine followed by no phentolamine (4L). Pharmacokinetic parameters estimated for phentolamine, lidocaine, and epinephrine included peak plasma concentration (Cmax), time to peak plasma concentration (Tmax), area under the plasma concentration-time curve from 0 to the last time point (AUClast) or from time 0 to infinity (AUCinf), elimination half-life (t1/2), clearance (CL), and volume of distribution (Vd). The phentolamine Tmax occurred earlier following the intravenous administration of 1Piv (7 minutes than following its submucosal administration in treatment 1L1P (15 minutes) or 4L2P (11 minutes). The phentolamine t1/2, CL, and Vd values were similar for 1L1P, 1Piv, and 4L2P. The Tmax for lidocaine occurred later and the Cmax for lidocaine was slightly higher when comparing the 4L2P treatment and the 4L treatment. The phentolamine-induced delay of the lidocaine Tmax likely represents phentolamine's ability to accelerate the systemic absorption of lidocaine from oral tissues into the systemic circulation.

Figure 1

The plasma concentration–time curves for phentolamine following the administration of phentolamine 0.4 mg intravenously (1Piv; closed triangle), phentolamine 0.4 mg submucosally (1L1P; closed circle), and phentolamine 0.8 mg submucosally (4L2P; open square). Lidocaine (LA) was administered 30 minutes (−0.5 hours) prior to phentolamine administration (T₀ hours).

Figure 2

The plasma concentration–time curves for lidocaine following the administration of 1 cartridge of 2% lidocaine 1 : 100,000 epinephrine followed after 30 minutes with 1 cartridge of phentolamine (1L1P; open circle); 4 cartridges of 2% lidocaine 1 : 100,000 epinephrine followed after 30 minutes with 2 cartridges of phentolamine (4L2P; open square); and 4 cartridges of 2% lidocaine 1 : 100,000 epinephrine followed by no phentolamine (4L; closed square). Lidocaine (LA) was administered 30 minutes (−0.5 hours) prior to phentolamine administration (T₀ hours).