Lignocaine ‘a feasible alternative analgesic’ to fentanyl in non-STEMI, unstable angina
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For patients with unstable angina or non-STEMI referred for coronary angiography, the use of fentanyl as an analgesic for chest pain slowed the absorption of ticagrelor, resulting in greater platelet reactivity compared with lignocaine.
The tolerability of lignocaine, compared with fentanyl was similar, and there was no significant difference in 30-day major adverse events, according to data presented at the European Society of Cardiology Congress.
“Unlike intravenous lignocaine, fentanyl delayed and impaired the absorption of ticagrelor leading to early high on-treatment platelet reactivity. Lignocaine was well tolerated in this setting and is a feasible alternative analgesic to opioids for procedural analgesia,” Himawan Fernando, MBBS, cardiologist at the Alfred Hospital in Melbourne, Australia, said during a presentation.
The LOCAL trial enrolled 90 patients undergoing coronary angiography for unstable angina or non-STEMI at the Alfred Hospital. Patients were randomly assigned to IV lignocaine or IV fentanyl. The mean lignocaine dose was 85 mg and the mean fentanyl dose was 99 mcg. All patients received ticagrelor 180 mg (Brilinta, AstraZeneca). The primary outcome was ticagrelor plasma levels. Other outcomes of interest included platelet function, pain scores and the 30-day prevalence of major adverse events.
“The background for [the LOCAL trial] is the now well-established and concerning interaction between opioids and oral P2Y12 inhibitors and the fact that procedural analgesia with opioids is extremely common in Australasia and worldwide,” Fernando said.
Researchers reported lower plasma ticagrelor levels at 2 hours among patients who received fentanyl compared with those who received lignocaine (598 ng/mL vs. 1,008 ng/mL; P = .014).
For all time points post-loading, platelet reactivity was greater in patients who received fentanyl compared with lignocaine (P for 30 minutes < .001; P for 1 hour < .001; P for 2 hours < .001; P for 4 hours = .001).
Overall, pain scores were low and there were no significant between-group differences in pain or tolerability of lignocaine compared with fentanyl.
Moreover, there was no difference in the prevalence of 30-day major adverse events between the fentanyl or lignocaine groups.
“Our results support the investigation of alternative analgesics to opioids for ischemic chest pain in ST-elevation myocardial infraction, which we are testing in the currently enrolling AVOID 2 STEMI RCT.” Fernando said.
The results were simultaneously published in the European Heart Journal.
Reference:
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Fernando H. Congress committee e-posters choice in pharmacology and pharmacotherapy. Presented at: European Society of Cardiology Congress; Aug. 27-30, 2021 (virtual meeting).
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