Version July 2025
Note: The effective anesthetic dose varies with procedure, intensity of anesthesia needed, duration of anesthesia required, and physical condition of the patient. Always use the lowest effective dose along with careful aspiration prior to administration.
Dental anesthesia:
Initial: 40 to 80 mg (1 to 2 mL) of prilocaine hydrochloride as a 4% solution with epinephrine 1:200,000
Maximum dose (weight-based) within a 2-hour period: Prilocaine hydrochloride (Ref):
<70 kg: 6 mg/kg (400 mg)
≥70 kg: 400 mg or 5 to 6 cartridges
There are no dosage adjustments provided in manufacturer's labeling; use with caution (renally metabolized).
There are no dosage adjustments provided in manufacturer's labeling; use with caution (hepatically metabolized).
Refer to adult dosing.
Dental anesthesia:
Children <10 years: Doses >40 mg (1 mL) of prilocaine hydrochloride as a 4% solution with epinephrine 1:200,000 are rarely needed for procedures involving a single tooth, in a maxillary infiltration for 2 to 3 teeth, or for an entire quadrant with a mandibular block.
Children >10 years: Refer to adult dosing.
There are no dosage adjustments provided in manufacturer’s labeling; use with caution (renally metabolized).
There are no dosage adjustments provided in manufacturer’s labeling; use with caution (hepatically metabolized).
There are no adverse reactions listed in the manufacturer’s labeling. See individual agents.
Hypersensitivity to local anesthetics of the amide-type or any component of the formulation; congenital or idiopathic methemoglobinemia
Concerns related to adverse effects:
• CNS toxicity: Careful and constant monitoring of the patient's state of consciousness should be done following each local anesthetic injection; at such times, restlessness, anxiety, tinnitus, dizziness, blurred vision, tremors, depression, or drowsiness may be early warning signs of CNS toxicity. Treatment is primarily symptomatic and supportive.
• Methemoglobinemia: Has been reported with local anesthetics; clinically significant methemoglobinemia requires immediate treatment along with discontinuation of the anesthetic and other oxidizing agents. Onset may be immediate or delayed (hours) after anesthetic exposure. Patients with glucose-6-phosphate dehydrogenase deficiency, congenital or idiopathic methemoglobinemia, cardiac or pulmonary compromise, exposure to oxidizing agents or their metabolites, or infants <6 months of age are more susceptible and should be closely monitored for signs and symptoms of methemoglobinemia (eg, cyanosis, headache, rapid pulse, shortness of breath, lightheadedness, fatigue). Use is contraindicated in patients with congenital or idiopathic methemoglobinemia.
• Respiratory arrest: Local anesthetics have been associated with rare occurrences of sudden respiratory arrest.
• Seizures: Convulsions due to systemic toxicity leading to cardiac arrest have also been reported, presumably following unintentional intravascular injection.
Disease-related concerns:
• Cardiovascular disease: Use with caution in patients with cardiovascular disease; should be used in minimal amounts in patients with significant cardiovascular disease (because of epinephrine component).
• Familial malignant hyperthermia: Prilocaine may potentially trigger malignant hyperthermia; follow standard protocol for identification and treatment.
• Hepatic impairment: Use with caution in patients with hepatic impairment; amide-type anesthetics are hepatically metabolized.
• Hyperthyroidism: Should be avoided in patients with uncontrolled hyperthyroidism.
• Vascular disease: Local anesthetic solutions containing a vasoconstrictor should be used cautiously. Patients with peripheral vascular disease or hypertensive vascular disease may exhibit exaggerated vasoconstrictor response, possibly resulting in ischemic injury or necrosis.
Special populations:
• Acutely ill patients: Use with caution in acutely ill patients; reduce dose consistent with age and physical status.
• Debilitated patients: Use with caution in debilitated patients; reduce dose consistent with age and physical status.
• Older adult: Use with caution in older adults; reduce dose consistent with age and physical status.
• Pediatric: Use with caution in children; reduce dose consistent with age and physical status.
Dosage form specific issues:
• Sodium metabisulfite: May contain sodium metabisulfite; use caution in patients with asthma or a sulfite allergy.
Other warnings/precautions:
• Administration: Intravascular injections should be avoided; aspiration should be performed prior to administration; the needle must be repositioned until no return of blood can be elicited by aspiration; however, absence of blood in the syringe does not guarantee that intravascular injection has been avoided.
• Appropriate dosing: To avoid serious adverse effects and high plasma concentrations, the lowest dosage resulting in effective anesthesia should be administered. Repeated doses may significantly increase blood concentrations of both the drug or its metabolites; tolerance to elevated blood concentrations varies with patient status. Reduced dosages, commensurate with age and physical condition, should be given to patients who are debilitated or acutely ill, and in older adults or the pediatric population.
• Trained personnel: Dental practitioners using local anesthetic agents should be well trained in diagnosis and management of emergencies that may arise from the use of these agents. Resuscitative equipment, oxygen, and other resuscitative drugs should be available for immediate use.
No
Solution (Citanest Forte Dental Injection)
4%-1:200000 (per mL): $0.56
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution [for dental use]:
Citanest Forte Dental: Prilocaine hydrochloride 4% and epinephrine 1:200,000 (1.8 mL) [contains sodium metabisulfite]
Generic: Prilocaine hydrochloride 4% and epinephrine 1:200,000 (1.8 mL)
Dental anesthesia: Local, infiltrative, or nerve block anesthesia in dental procedures
Refer to individual components.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Alpha1-Blockers: May decrease therapeutic effects of Alpha-/Beta-Agonists. Risk C: Monitor
Antidiabetic Agents: Hyperglycemia-Associated Agents may decrease therapeutic effects of Antidiabetic Agents. Risk C: Monitor
Articaine: May increase adverse/toxic effects of Local Anesthetics. Risk C: Monitor
Atomoxetine: May increase hypertensive effects of Sympathomimetics. Atomoxetine may increase tachycardic effects of Sympathomimetics. Risk C: Monitor
Azosemide: May decrease therapeutic effects of EPINEPHrine (Systemic). Risk C: Monitor
Benperidol: May decrease therapeutic effects of EPINEPHrine (Systemic). Risk C: Monitor
Benzylpenicilloyl Polylysine: Coadministration of Alpha-/Beta-Agonists and Benzylpenicilloyl Polylysine may alter diagnostic results. Management: Consider use of a histamine skin test as a positive control to assess a patient's ability to mount a wheal and flare response. Risk D: Consider Therapy Modification
Beta-Blockers (Beta1 Selective): May decrease therapeutic effects of EPINEPHrine (Systemic). Risk C: Monitor
Beta-Blockers (Nonselective): May increase hypertensive effects of EPINEPHrine (Systemic). Risk C: Monitor
Beta-Blockers (with Alpha-Blocking Properties): May decrease therapeutic effects of EPINEPHrine (Systemic). Risk C: Monitor
Blonanserin: May decrease therapeutic effects of EPINEPHrine (Systemic). Risk X: Avoid
Bornaprine: Sympathomimetics may increase anticholinergic effects of Bornaprine. Risk C: Monitor
Bretylium: May increase therapeutic effects of Alpha-/Beta-Agonists (Direct-Acting). Risk C: Monitor
Bromocriptine: May increase hypertensive effects of Alpha-/Beta-Agonists. Management: Consider alternatives to this combination when possible. If combined, monitor for hypertension and tachycardia, and do not coadminister these agents for more than 10 days. Risk D: Consider Therapy Modification
Bromperidol: May decrease therapeutic effects of EPINEPHrine (Systemic). Risk X: Avoid
BUPivacaine (Liposomal): Local Anesthetics may increase adverse/toxic effects of BUPivacaine (Liposomal). Management: Liposomal bupivacaine should not be administered with local anesthetics, but may be administered 20 minutes or more after lidocaine. Avoid all local anesthetics within 96 hours after administration of liposomal bupivacaine. Risk X: Avoid
BUPivacaine: Local Anesthetics may increase adverse/toxic effects of BUPivacaine. Management: Avoid using any additional local anesthetics within 96 hours after insertion of the bupivacaine implant (Xaracoll) or bupivacaine and meloxicam periarticular solution (Zynrelef) or within 168 hours after subacromial infiltration (Posimir brand). Risk C: Monitor
Cannabinoid-Containing Products: May increase tachycardic effects of Sympathomimetics. Risk C: Monitor
Cardiac Glycosides: EPINEPHrine (Systemic) may increase arrhythmogenic effects of Cardiac Glycosides. Risk C: Monitor
Chloroprocaine (Systemic): May increase hypertensive effects of Alpha-/Beta-Agonists. Risk C: Monitor
Chlorprothixene: May increase adverse/toxic effects of EPINEPHrine (Systemic). Specifically, paradoxical hypotension and tachycardia may be increased. EPINEPHrine (Systemic) may increase therapeutic effects of Chlorprothixene. Risk C: Monitor
CloZAPine: May decrease therapeutic effects of Alpha-/Beta-Agonists. Risk C: Monitor
Cocaine (Topical): May increase hypertensive effects of Sympathomimetics. Management: Consider alternatives to use of this combination when possible. Monitor closely for substantially increased blood pressure or heart rate and for any evidence of myocardial ischemia with concurrent use. Risk D: Consider Therapy Modification
COMT Inhibitors: May increase serum concentration of COMT Substrates. Risk C: Monitor
Dapsone (Topical): May increase adverse/toxic effects of Methemoglobinemia Associated Agents. Risk C: Monitor
Dihydralazine: Sympathomimetics may decrease therapeutic effects of Dihydralazine. Risk C: Monitor
Diuretics: May increase arrhythmogenic effects of EPINEPHrine (Systemic). Diuretics may decrease vasopressor effects of EPINEPHrine (Systemic). Risk C: Monitor
Doxofylline: Sympathomimetics may increase adverse/toxic effects of Doxofylline. Risk C: Monitor
Ergot Derivatives (Vasoconstrictive CYP3A4 Substrates): May increase vasoconstricting effects of Alpha-/Beta-Agonists. Risk X: Avoid
Esketamine (Injection): May increase adverse/toxic effects of Sympathomimetics. Specifically, the risk for elevated heart rate, hypertension, and arrhythmias may be increased. Risk C: Monitor
Guanethidine: May increase hypertensive effects of Sympathomimetics. Guanethidine may increase arrhythmogenic effects of Sympathomimetics. Risk C: Monitor
Haloperidol: May decrease vasoconstricting effects of EPINEPHrine (Systemic). Management: Consider alternatives to this combination and monitor for reduced epinephrine efficacy, and possible paradoxical effects (ie, hypotension), when combined. Use of alternative vasopressor agents (eg, phenylephrine, metaraminol, norepinephrine) is preferred. Risk D: Consider Therapy Modification
Hexoprenaline: May increase adverse/toxic effects of Alpha-/Beta-Agonists. Risk X: Avoid
Hyaluronidase: May increase vasoconstricting effects of Alpha-/Beta-Agonists. Management: Do not use hyaluronidase to enhance the dispersion or absorption of alpha-/beta-agonists. Use of hyaluronidase for other purposes in patients receiving alpha-/beta-agonists may be considered as clinically indicated. Risk D: Consider Therapy Modification
Inhalational Anesthetics: May increase arrhythmogenic effects of EPINEPHrine (Systemic). Management: Administer epinephrine with added caution in patients receiving, or who have recently received, inhalational anesthetics. Use lower than normal doses of epinephrine and monitor for the development of cardiac arrhythmias. Risk D: Consider Therapy Modification
Isoproterenol: May increase therapeutic effects of EPINEPHrine (Systemic). Risk X: Avoid
Kratom: May increase adverse/toxic effects of Sympathomimetics. Risk X: Avoid
Levothyroxine: May increase therapeutic effects of Sympathomimetics. Sympathomimetics may increase therapeutic effects of Levothyroxine. Levothyroxine may increase adverse/toxic effects of Sympathomimetics. Specifically, the risk of coronary insufficiency may be increased in patients with coronary artery disease. Risk C: Monitor
Linezolid: May increase hypertensive effects of Sympathomimetics. Management: Consider initial dose reductions of sympathomimetic agents, and closely monitor for enhanced blood pressure elevations, in patients receiving linezolid. Risk D: Consider Therapy Modification
Lisuride: May increase hypertensive effects of Alpha-/Beta-Agonists. Risk X: Avoid
Local Anesthetics: Methemoglobinemia Associated Agents may increase adverse/toxic effects of Local Anesthetics. Specifically, the risk for methemoglobinemia may be increased. Risk C: Monitor
Melperone: May increase adverse/toxic effects of EPINEPHrine (Systemic). Risk C: Monitor
Methemoglobinemia Associated Agents: May increase adverse/toxic effects of Local Anesthetics. Specifically, the risk for methemoglobinemia may be increased. Risk C: Monitor
Methemoglobinemia Associated Agents: May increase adverse/toxic effects of Prilocaine. Combinations of these agents may increase the likelihood of significant methemoglobinemia. Management: Monitor for signs of methemoglobinemia when prilocaine is used in combination with other agents associated with development of methemoglobinemia. Avoid use of these agents with prilocaine/lidocaine cream in infants less than 12 months of age. Risk C: Monitor
Monoamine Oxidase Inhibitors: May increase hypertensive effects of EPINEPHrine (Systemic). Risk C: Monitor
Neuromuscular-Blocking Agents: Local Anesthetics may increase neuromuscular-blocking effects of Neuromuscular-Blocking Agents. Risk C: Monitor
Nitric Oxide: May increase adverse/toxic effects of Methemoglobinemia Associated Agents. Combinations of these agents may increase the likelihood of significant methemoglobinemia. Risk C: Monitor
Pergolide: May increase hypertensive effects of Alpha-/Beta-Agonists. Risk C: Monitor
Primaquine: Methemoglobinemia Associated Agents may increase adverse/toxic effects of Primaquine. Specifically, the risk for methemoglobinemia may be increased. Management: Avoid concomitant use of primaquine and other drugs that are associated with methemoglobinemia when possible. If combined, monitor methemoglobin levels closely. Risk D: Consider Therapy Modification
Promethazine: May decrease vasoconstricting effects of EPINEPHrine (Systemic). Management: Avoid epinephrine and consider norepinephrine or phenylephrine when treating hypotension due to promethazine overdose. Consider alternative vasocontrictors in patients treated with promethazine. This combination may be indicated in anaphylaxis treatment. Risk D: Consider Therapy Modification
ROPivacaine: May increase adverse/toxic effects of Local Anesthetics. Risk C: Monitor
Serotonin/Norepinephrine Reuptake Inhibitor: May increase tachycardic effects of Alpha-/Beta-Agonists. Serotonin/Norepinephrine Reuptake Inhibitor may increase vasopressor effects of Alpha-/Beta-Agonists. Management: If possible, avoid coadministration of direct-acting alpha-/beta-agonists and serotonin/norepinephrine reuptake inhibitors. If coadministered, monitor for increased sympathomimetic effects (eg, increased blood pressure, chest pain, headache). Risk D: Consider Therapy Modification
Solriamfetol: Sympathomimetics may increase hypertensive effects of Solriamfetol. Sympathomimetics may increase tachycardic effects of Solriamfetol. Risk C: Monitor
Spironolactone: May decrease vasoconstricting effects of Alpha-/Beta-Agonists. Risk C: Monitor
Sympathomimetics: May increase adverse/toxic effects of Sympathomimetics. Risk C: Monitor
Technetium Tc 99m Tilmanocept: Coadministration of Local Anesthetics and Technetium Tc 99m Tilmanocept may alter diagnostic results. Management: Avoid mixing and simultaneously co-injecting technetium Tc 99m tilmanocept with local anesthetics. This interaction does not appear to apply to other uses of these agents in combination. Risk C: Monitor
Tedizolid: May increase adverse/toxic effects of Sympathomimetics. Specifically, the risk for increased blood pressure and heart rate may be increased. Risk C: Monitor
Tricyclic Antidepressants: May increase vasopressor effects of Alpha-/Beta-Agonists. Management: Avoid, if possible, the use of alpha-/beta-agonists in patients receiving tricyclic antidepressants. If combined, monitor for evidence of increased pressor effects and consider reductions in initial dosages of the alpha-/beta-agonist. Risk D: Consider Therapy Modification
Vasopressin: Alpha-/Beta-Agonists (Direct-Acting) may increase hypertensive effects of Vasopressin. The effect of other hemodynamic parameters may also be enhanced. Risk C: Monitor
Adverse events were not observed in animal reproduction studies.
Usual infiltration doses of prilocaine with epinephrine given to nursing mothers has not been shown to affect the health of the nursing infant.
Cardiovascular and respiratory vital signs; state of consciousness after each injection; CNS toxicity
Local anesthetics bind selectively to the intracellular surface of sodium channels to block influx of sodium into the axon. As a result, depolarization necessary for action potential propagation and subsequent nerve function is prevented. The block at the sodium channel is reversible. When drug diffuses away from the axon, sodium channel function is restored and nerve propagation returns.
Epinephrine prolongs the duration of the anesthetic actions of prilocaine by causing vasoconstriction (alpha-adrenergic receptor agonist) of the vasculature surrounding the nerve axons. This prevents the diffusion of prilocaine away from the nerves resulting in a longer retention in the axon.
Onset of action: Infiltration: <2 minutes; Inferior alveolar nerve block: <3 minutes
Duration: Infiltration: ~2.25 hours; Inferior alveolar nerve block: ~3 hours
