Adjuvants/co-analgesics: antiarrhythmic drugs
The cardiac antiarrhythmic drugs mexiletine, flecainide and lignocaine are membrane stabilisers that are used in neuropathic pain that is refractory to other adjuvant therapy. Lignocaine can be used as a diagnostic test for neuropathic pain, with prolonged pain relief achieved at times. It has also been used as a continuous subcutaneous infusion for relief of neuropathic pain. Intrathecal lignocaine has been used, but the more commonly used local anaesthetic agent in spinal analgesia is bupivacaine. Lignocaine has also been used as an inhalation in the management of persistent cough. These agents are not first-line drugs and are generally used after a trial of tricyclic antidepressants (TCAs) and antiepileptics
All these antiarrhythmic agents can have serious adverse effects and many drug interactions, and have the potential to worsen arrhythmias. Tricyclic antidepressants (TCAs) should generally be stopped 48 hours before starting one of these drugs. Consultation with a palliative care specialist, a pain physician, or a pain clinic is strongly recommended before using antiarrhythmic drugs for pain management.
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