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 Management Tip 29 What Drugs, What Bugs and What the Holistics Believe UCSF Continuing
Education Course Outline of course presented by Joseph D. Maggio, D.D.S. Patient's Information Demographics: Name, age, weight
Medication
Medical History
.bronchitis, seasonal allergies .respiratory or inflammatory disorders
Medical History .Infection
.Allergy .Food allergy
.Drug allergy
.Latex allergy Medical History .Respiratory
.Inflammatory conditions
.Trauma: May be taking analgesics or muscle relaxants Medical History .Angina
pectoris .Arrhythmias .MI: Recent should not tx. .Congenital,
rheumatic fever, murmurs
.Stroke Medical History .Diabetes
.Hyperthyroidism
Medical History .Ulcers -increased risk of GI problems with ASA and NSAIDs -anti-ulcer drugs decrease efficacy of antifungal drugs prescribed by dentists .Hepatitis, Jaundice, Cirrhosis -may need lower doses of NO, LA, behavior modifying drugs, and pain medications Medical History .Cardiovascular -arrhythmias or blood pressure .Endocrine -Diabetes -Thyroid .Gastrointestinal/Liver -Ulcers -Hepatitis, jaundice, cirrhois .Geniturinary .Hematopoietic -Anemia -Bleeding disorders -Anticoagulation .Musculosketal -Arthritis .Neurologic -Epilepsy -Psychiatric Tx -Parkinson's .Respiratory -asthma, COPD, emphysema Medical History .Bleeding disorders -may need prophylactic antibiotics -may need to avoid ASA and NSAIDs .Anticoagulation -increased risk of bleeding -antibiotics prescribed by dentist may increase bleeding -avoid use of ASA and NSAIDs Medical History .Kidney failure -Need low doses of many drugs -Must avoid use of ASA and NSAIDs .Kidney transplant -suppressed immune system .decreased healing .increased risk of infection -prophylax with antibiotics -avoid ASA and NSAIDs Medical History .Arthritis .Osteoarthritis -probably taking ASA, salicylates or NSAIDs .increase risk of bleeding with dental procedure .Rheumatoid -probably taking immunosuppressant .increased risk of infection .Fractures Medical History .Epilepsy .Parkinson's .Psychiatric medication .Medication often sedating Medical History .Bronchodilators
are stimulants .Increased risk of respiratory complications with sedative drugs prescribed by dentist Medication History .Ask open-ended not yes/no questions .Drugs should correspond to conditions .Ask specifically what is taken for each condition -prescription -OTC -herbal/supplement .Best if patients bring their medication bottles with them .If patient can't remember name of medication, ask for pharmacy name and call pharmacist Medication History .Reactions to drugs -avoid using the term "allergic reaction" to begin with -ask patient to identify drug and describe reaction .Side effects .Toxic effects .Idiosyncratic reaction .Altered host response .Allergy Medication History .Prescription Medications -for each condition listed -hormones -contraception -headache -cough and cold -aches and pains -sleep -mood/anxiety .Non-prescription Medications -for each condition listed -headache -cough and cold -aches and pains -sleep -indigestion -vitamins, minerals Medication History .Herbals/Nutritional Supplements -For each condition listed .hormones .headache .cough and cold .aches and pains .sleep .indegestion .vitamins, minerals .energy .youth .strength, body building .sexual function .depression Top Therapeutic Categories of Prescription Drugs 2002 .Cholesterol Drugs .Cardiovascular Drugs .Gastrointestinal Drugs .Respiratory Drugs .Psychotherapeutic Drugs .Cancer Drugs .Anti-infective Agents .Blood Disorder Treatments .Anti-arthritic Drugs .Diabetic Drugs .Anticonvulsants .Bone Metabolism Regulators .AIDS Drugs .Multiple Sclerosis Drugs .Urinary Tract Agents .Immunosuppressants .Hormones .Vaccines .Sexual Dysfunction Therapies .Analgesics .Migraine Drugs .Opthalmic Products .Sedative and Hypnotics Medication
History -Aspirin -Dipyridamole (Persantin) -Ticlopidine HCl (Ticlid) -Anagrelide HCl (Agrylin) -Clopidogrel (Plavix) -Sulfinpyrazone (Anturane) .Importance to Dentistry -Do not prescribe aspirin or NSAIDs alone or in combination -Caution patients about increased bleeding during and after antibiotic therapy Medication
History .ACE Inhibitors -Zestril -Titrace/Delix -Vasotec, Vaseretic -Accupril, Accuretic -Prinivil, Prinizide -Altace -Lotensin/Cibacen .Beta-blockers -Atenolol -Topprol-XL/Seloken -Coreg .Diuretics -Furosemide -Triamterene/HCTZ -HCTZ Medication
History .ACE Inhibitors .Beta-blockers .Diuretics .Patients more prone to hypotension -orthostatic or postural hypotension .NSAIDs prescribed by dentist can decrease effectiveness of anti-hypertensive therapy Medication
History .Calcium Channel Blockers -Cardizem CD -Procardia XL -Adalat CC -Verapamil SR .Importance to Dentistry -gingival hyperplasia Medication History .SSRI-Selective Serotonin Reuptake Inhibitors -Prozac, Prozac weekly, Sarafem -Zoloft -Paxil/Seroxat -Celexa .SNRI-Serotonin and Norepinephrine Reuptake Inhibitors -Wellbutrin, Wellbutrin SR -Amitriptyline HCl -Effexor, Effexor XR -Remeron Medication
History .Lower seizure threshold -more sensitive to LA .Some SNRI are CNS depressants .Serotonin Syndrome -interact with Demerol Medication
History .Pencillin -Veetids -Pencillin VK .Amoxicillin -Trimox -Augmentin -Amoxicillin Trihydrate -Amoxil .Cephalosporins -Cephalexin -Cefzil -Ceftin -Rocephin .Extended Spectrum Macrolides -Zithromax Z-Pak -Biaxin -Zithromax -Ery-Tab .Quinolones -Cipro/Ciprobay -Levaquin -Floxin -Cravit Medication
History .Penicillin .Amoxicillin .Cephalosporins .Extended Spectrum Macrolides .Quinolones .Drug Allergy -Penicillin, amoxicillin, cephalosporin .Increased bleeding .Overgrowth of opportunistic infections -fungal, yeast, viral Medication
History .NSAIDs -Ibuprofen -Relafen -Naproxen -Voltaren .COX-2 Inhibitors -Celebrex -Vioxx(NO MORE) -Mobic -Bextra Medication
History .NSAIDs .COX-2 Inhibitors .Anti-platelet effects -NSAIDs>COX-2 -Increased bleeding .GI effects -NSAIDs>COX-2 -Additive with other GI irritants Medication
History .Estrogen Replacement Therapy -Premarin, Prempro, Premphase .Oral Contraceptives .Importance to Dentistry -Antibiotics prescribed by dentist decrease effectiveness -OC .counsel patients to use another form of protections during entire cycle Medication
History .Potent vasodilator .Contraindicated in patients taking nitrates -caution with other vasodilators .Anti-hypertensives .Importance to Dentistry -Vasodilators contraindicated in patients taking Viagra .Cannot
use NTG for angina attack -Caution
prescribing enzyme inhibitors .erthromycin,
Biaxin Medication History .Strong pain relievers -Opioids/combinations .Hydrocodone with APAP .Codeine with APAP .Propoxyphene-N/APAP .Oxycontin .Oxycodone with APAP .Duragesic .Tramadol (Ultram) -Ultracet .Anxiety Drugs -Benzodiazepines .Alprazolam (Xanax) .Lorazepam .Clonazepam .Diazepam .Temazepam .Zolpidem tartrate (Ambien)/Stilnox Medication History .Strong pain relievers .Anxiety drugs .Sedative/Hypnotics .Increased sedation and risk of respiratory depression with analgesics and behavior modifying drugs used or prescribed by dentist Medication
History .Importance to Dentistry -Do not prescribe aspirin or NSAIDs alone or in combination -Caution patients about increased bleeding during antibiotic therapy -Effects increased by Cipro, Diflucan, Erythromycin, Biaxin What is a Dietary Supplement? A dietary supplement is a product that contains one or more of the following: vitamin, mineral, herb or other botanical, an amino acid, a dietary substance for use by man to supplement the diet by increasing the total daily intake, or a concentrate, metabolite, constituent, extract, or combination of these ingredients Dietary Supplement Health and Education Act (DSHEA) .Dietary Supplement Health and Education Act (DSHEA) of 1994 .Unregulated supplement sale with restricted labeling DSHEA and the Supplement Market .Section 6 of the Act permits limited claims regarding the health benefit of dietary supplements .No health and disease claims permitted .No supporting evidence required for sale of botanicals or vitamins .Structure-function (SF) claims but no disease-cure claims DSHEA Example ."Cranberry helps maintain a healthy urinary tract" ."Cranberry helps to prevent urinary tract infection" .Cranberry helps to maintain a healthy urinary tract by inhibiting the adhesion of E.coli bacteria to the wall of the ureter" .Correct
Structure Function Claim: .Cannot claim to treat, prevent, mitigate, or cure disease .Cannot
include mechanism of action showing
how the dietary supplement is
believed to work A few facts about herbals and supplements .About $5 billion a year spent on herbals and supplements .40% of your patients take them .18% of your patients take them along with prescriptions .80% won't tell you Dietary
Supplement Sales Alternative Medicine Survey 15 million adults in 1997 took prescription medication concurrently with herbal remedies and/or high-dose vitamins (18.4% of all prescription users) David M. Eisenberg, MD; Roger B. Davis, ScD; Susan L. Ettner, PhD; Scott Appel, MS; Sonja Wilkey; Maria Van Rompay; Ronald C. Kessler, PhD. Trends in Alternative Medicine Use in the United States, 1990-1997 Results of a Follow-up National survey. JAMA. 1998; 280:1569-1575 Slone Survey .Herbals/supplements were taken by 14% of the population .Among prescription drug users, 16% also took an herbal/supplement .Rate of concurrent use was highest for fluoxetine(Prozac) users, at 22% .Reasons for drug use varied widely, with hypertension and headache mentioned most often 9% for each Supplement User Profile .In the year 2000, 37% of all households reported using herbal supplements .Herbal supplements users tend to be older (almost 60% over 45 years of age and in older life stages), and well-educated (a significant number have post-graduate degrees) -Health and Wellness Trends Report (HWTR), which includes information on consumer attitudes, behaviors and motivations across 16 shopping channels, more than 90 product categories, more than 80 attitudes/beliefs, plus much more. Supplement User Profile .More than 42% live in large cities (defined as having populations more than 2 million), and they have slightly higher income levels than the general population, a fact most likely driven by their education levels .They are self-care seekers: 65% more likely than the general population to use alternative healthcare services and 18% more likely to use over-the-counter (OTC) medications Predictors of Patients Who are Likely to Use Herbal Remedies .Female .One or both parents born outside of the U.S. .College graduate How These Data May Be Applied in the Clinical Practices .Recognize that about half of all patients using alternatives -Are not aware of potential for drug interactions -Have not informed you .Hispanic patients and patients with both parents born outside of the US are more likely to use home remedies than other patients. Why the interest in herbals? .Desire to control medical care ."Back to nature" movement ."Impersonal" nature of medical care .Hype and economics .Scientific illiteracy .Internet Herbal Products and Surgery .Several studies have shown that patients undergoing surgery were more frequent users of herbal remedies than the general population (22-33%) .70% of those patients taking these products failed to disclose this information during routine perioperative assessment Ang-Lee, MK et al. Herbal therapies and perioperative care. JAMA 2001 ;268(2):208-214. Why are patients reluctant to tell you about herbal use? .Fear of ridicule .Consider the problem "low level" ."Herbals" aren't "medicines" ."If it's natural, it's safe" .Not worth bothering dentist "Hot" Indications for Herbal Use .Menopause .Libido enhancement .Depression .Mentation .Hypertension .Cardiac Disease .Weight Loss .Immune Stimulation .Stress .Sleep ."Detoxification" Top 20 Herbs in U.S.-2000 Ranking Top 20 Herbs in
U.S.-2000 Ranking Mechanism of Interactions .Altered drug absorption .Altered renal elimination of drugs .Additive effect or toxicities .Altered hepatic metabolism of drugs Additive Effect or Toxicities .Licorice and sympathomimetic herbs (Ephedra) can reduce the therapeutic effect of antihypertensive medications. .Mechanism:
Increased salt and water retention .Opposition
of therapeutic action Grapefruit Juice-Drug Interaction .Numerous studies have demonstrated that GJ increases the concentration of many drugs in humans .Drugs and GJ metabolized via the Cytochrome P450 system .Concomitant use increases plasma peak concentration of drugs .Furanocumarin components of GJ are responsible Medications that Interact with GJ .Amiodarone .Cyclosporine .Cisapride .Carbamazepine .Benzodiazepines .Statins- Lovastatin, Simvastatin, Atorvastatin .Saquinavir .Verapamil .Dihydropyridine
calcium channel blockers-Nifedipine,
Felodipine, Amlodipine Defining herbal activity .Preparations vary from batch to batch; concentrations vary from plant to |