Transcript Patient presents to MD office for routine check up.

JOE ALAMAT DDS, MD
SUMMIT ORAL AND MAXILLOFACIAL SURGERY
[email protected]
(586)703-7104)
Medication List
 Learn to decipher the patient’s medical history
through medication lists.
 Know why they are on the medications
 What precautions should be taken
 Learn to think like the PCP.
Topics that will be covered
 CVS
 Diabetes
 Immunocompromised
 Pregnancy
 Oral Cancer
 Osteoporosis
Cardiovascular diseases
 Two disease entities will be covered:
 Hypertension
 Myocardial infarction
Traditional Vs Functional Medicine
 Traditional medicine teaches us that hypertension is a
disease that is diagnosed by elevated systolic and or
diastolic pressures. Treatment is focused on decreasing
the blood pressure readings by medications.
 Integrative medicine recognizes that hypertension is a
symptom of underlying endothelial dysfunction
secondary to inflammation and increased oxidative
stress. Treats patients by exercise, diet, micronutrient
replacement such as Zn, Vit C, in addition to
medications
•Preload
•Afterload
•Ejection fraction
HTN
 Patient presents for routine check up
 Bp is 175/95
 HTN confirmed three time at least a week apart 140/90
or use ambulatory blood pressure monitors.
 Single diastolic reading of 110 is confirmation of HTN
Complications of HTN
 The problems associated with HTN or increased
afterload
 Heart has to pump with more force to overcome the
pressure
 Cardiac hypertrophy and eventually left ventricular
dysfunction develops
 End organ damage (fundoscopic, renal, brain) all
associated with vascular damage
How can we decrease the pressure
in this closed system
• Decrease pump strength
•Increase the volume in arteries
•Increase volume in the veins
•Decrease fluid in the system
Medications To Treat HTN
 Beta blockers (olols) decrease pump strength and
speed
 Diuretics (Lasix, Lozol, HCTZ) decrease fluid in the
system
 Ace inhibitors (prils) decrease the fluid resorption in
the kidneys and prevents angiotensin from developing
Medications To Treat HTN
 Calcium channel blockers (norvasc etc) increase the
volume in the arteries
 ARBs block the vasoconstrictive effects of angiotensin
 Alpha antagonists (Terazosin) relax arteries and
increase the volume of the arteries
 Centrally acting (Clonidine) decrease sympathetic
outflow on the CVS
Mild HTN easily controlled based
on prescription
Moderate to Severe Hypertension
based on prescription
How would you address a
clearance
 The more meds a patient is on to control HTN, the
more labile the HTN
 Avoid excessive epi
Measure the BP
 Aspirate when injecting
 Calm environment
Always Check the BP
MI
 You are a cardiologist
called to the cath lab for a
patient with an STEMI.
You determine that the
LAD is occluded and
decide to place a stent.
 What are the next steps of
medical management?
 6-8 Meds are always
initially used.
Mi Management
 Decrease the preload ( blood return to heart) with
nitrates like nitrodur
MI Management
 Decrease the afterload (so the heart is not pumping
against high pressure so as not to stress the heart) BP
meds
 ARB
 Ace inhibitor
 Beta blocker
 etc
Mi Management
 Increase blood flow to the myocardium by using
nitrates
Mi Management
 Improve the lipid profile by using statins
Lipid profile drugs
 Cholesterol lowering medications
 Lipitor (went generic)
 Zocor
 They are both statins decrease production of cholesterol
 Zetia decreases absorption
 Zocor and Zetia called Vytorin
 Others are Crestor and Niaspan and Tricor
Mi Management
 Anticoagulate to prevent reocclusion of the stent and
dissolve or prevent thrombotic emboli .(antiplatelets)
 Aspirin
 Plavix
Anticoagulant
 Coumadin inhibits factors 10, 9, 7 and 2 from forming
in the liver. Half life 20-60hours
 Pradaxa (dabigatran): reversibly and directly inhibits
thrombin. Half life is 12-17 hours. No INR required.
 Xarelto (rivaroxaban) is a factor Xa inhibitor. Half life
5-9 hours.
 ADA council on scientific affairs stated that
antiplatelet and anticoagulant meds rarely need to be
discontinued prior to most dental procedures. The risk
for thromboembolic events exceeds the risk of
bleeding.
Never stop Plavix or ASA after a
recent MI
MI management
 Regulate the speed of the heart so that arrhythmias do
not develop.
Beta Blockers
 Used to treat HTN, angina and Migraines
 Work on the beta receptors and block them, unlike
asthma medications that stimulate the receptors
 Metoprolol (Lopressor) is a cardioselective med
MI management
 Amiodarone for ventricular tachycardia
Red Flags
 Coumadin s/p MI indicates significant ventricular
dysfunction secondary to ischemia.
 Amiodarone suggests that the patient has a history of
dangerous ventricular tachycardia and rhythm
Dental clearance
 Increased risk of problems in the first 6 months status
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post MI
Do Not stop Plavix or aspirin or coumadin
No epi
No Nsaids
Ask if patient gets shortness of breath.(Functional
Capacity)
Diabetes
 Fasting Glucose
 99 or below is normal
 100 to 125 Pre-diabetes impaired fasting glucose
 126 or above diabetes*
 Random glucose above 200
 Type I autoimmune
 Type two insulin resistance
Metabolic Syndrome
 The dominant underlying risk factors for this
syndrome appear to be abdominal obesity and insulin
resistance.
 Insulin resistance is a generalized metabolic disorder,
in which the body can’t use insulin efficiently.
 This is why the metabolic syndrome is also called the
insulin resistance syndrome
Metabolic Syndrome
 Some people are genetically predisposed to insulin
resistance.
 Acquired factors, such as excess body fat and
physical inactivity, can elicit insulin
resistance and the metabolic syndrome in these
people.
 Most people with insulin resistance have abdominal
obesity.
Diagnosis is three or more
 Elevated waist circumference:
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Men — Equal to or greater than 40 inches (102 cm)
Women — Equal to or greater than 35 inches (88 cm)
Elevated triglycerides:
Equal to or greater than 150 mg/dL
Reduced HDL (“good”) cholesterol:
Men — Less than 40 mg/dL
Women — Less than 50 mg/dL
Elevated blood pressure:
Equal to or greater than 130/85 mm Hg
Elevated fasting glucose:
Equal to or greater than 100 mg/dL
Manifestations of Metabolic
Syndrome
Skin Tags
Acanthosis Nigrans
Type of Obesity
Central Adiposity
Generalized adiposity
Diabetes meds
 Actos, Avandia
 Decreases insulin resistance
 Lantus
 Long acting injected insulin
 Byetta
 Increases insulin secretion
 Metformin
 Decreases absorption
Treatment of diabetes
 Oral Hypoglycemic
 Insulin if resistant or level high
 Weight modification
 ACE inhibitors if protein is in the urine to protect the
kidneys
 Usually associated with hypertriglyceridemia
 Usually treated with Niaspan
Functional Medicine
 In addition to Medications, supplements are used.
 Zinc
 Chromium
 ALA
 Vit D (sequestered in fat)
 CoQ10
 Omega 3
 Sleep
 Decrease stress levels
 Low Glycemic Index foods
Glycemic Index
 It measures how fast food raises the sugar level in the
blood
 Glucose has a GI of 100. shoot for foods less than 55
 E.g.
 Bagel 72
 Cornflakes 93
 Rice Cakes 82
Coco Pops 73
Pretzels 83
 Ice cream 57
 Apple 39
 Fruit roll Ups 99
M&& peanut 33
Dental clearance issues
 Minimize NSAIDs
 Watch for hypoglycemia
 Watch carefully for infections( use cidal meds such as
PCN Doc)
 Ask about their HBA1C
Immunocompromised patients
 Patients that fall in this category are numerous.
Among them are
 those on steroids over 20 of prednisone daily.
 Organ transplant patients
 Patients on chemotherapy
 Patients taking DMARDS( disease modifying anti
rheumatic drugs)
Transplant Patients
 Liver
 function is assessed by the PT which measures 1972.
Ask about increased bleeding, bilirubin etc. If tests are
okay then treat as an immunocompromised patient
 Kidney
 ask about the bun and creatinin. Should be 10, and 1
respectively. If tests okay treat as immunocompromised
patient
 Heart
 Ask about EF and CHF.
Transplant Patients
 Some of their meds include:
 Azathioprine
 Cellcept avoid motrin
 Cyclosporine avoid emycin, motrin
 Immuran
 Prograf avoid emycin, motrin
 GVHD lichenoid reactions
DMARDS
 Are used for autoimmune diseases such as chrons
disease, psoriasis, rheumatoid arthritis etc.
 Newer ones include TNF Inhibitors. These can be
Mabs such as:
 Adalimumab (Humira)
 Golimumab (Simponi)
 Infliximab (Remicaide)
 Or fusion proteins such as:
 Etanercept (Enbrel)
What are the “MABS”
 They are drugs that are Monoclonal AntiBodies.
 They are from animals
 Rats- AMAB
 Hamster-EMAB
 Primate- IMAB
 Mouse- OMAB
 Human-UMAB
 From human and animal mixed thus they are called chimeric
 XIMAB (Constant part is human)
 ZUMAB (variable is human)
 They are used in Cancer treatment, autoimmune disease,
osteoporosis, and many other uses.
Immunocompromised patients
 Beware of infections consider premedication
 Be aware of transient bacteremia from poor oral
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hygiene
Do not give NSAIDS
Do not give erythromycin or Z packs
DOC is tylenol or Ultram
Pen vk is DOC
Clinadamycin if that doesn’t work
Pregnancy
 Not a contraindication to treatment.
 Important points are pen vk, clindamycin are allowed
 Tylenol3, tylenol, vicodin are all permitted
 Absolutely no NSAIDS or steroids.
 Steroids are teratogenic
 NSAIDS shut down the ductus arterosis.
 Minimize epi.
 That is what is in a clearance.
Cancer Patients
 Prior to undergoing chemo treat any potential
source of infection. Be aggressive
 During chemo therapy treat only emergencies.
They are at high risk of fulminant infections and
surgery sites heal very slowly
 Use cidal antibiotics such as penicillin as first
therapy
 Arimidex or tamoxifen are used for ongoing breast
CA treatment
 Leupron for prostate CA
Cancer Patients
 Extract any tooth that is in the line of the beam if
radiation therapy is to be done always at a risk for
ORN
 Fluoride trays must be made
 Cleanings and exam every three months.
 Note about HPV (Cetiximab or Erbitux)
Osteoporosis
 In osteoporosis, the bone mineral density (BMD) is
reduced and bone microarchitecture deteriorates.
 Osteoporosis is defined by the World health
organization (WHO) as a bone mineral density of 2.5
standard deviations or more below the mean peak
bone mass (average of young, healthy adults) as
measured by dual energy X ray absorptiometry
Calcium
Metabolism
Osteoporosis Medications
Bisphosphonates
 At this time, FDA believes that the benefits of oral
bisphosphonate drugs in reducing the risk of serious
fractures in people with osteoporosis continue to
outweigh their potential risks.
 The agency’s analysis, which found little if any benefit
from the drugs after three to five years of use
Bisphosphonates
 Actonel (risedronate) PO
 Aredia (pamidronate) IV
 Boniva (ibandronate) IV
 Fosamax (alendronate)
 Reclast (zolendronate) once a year for osteoporosis IV
 Skelid (tiludronate) PO
 Zometa (zolendronate) Once a month for cancer IV
Osteoporosis drug may reduce
colon cancer risk
 Mayo clinic health letter 2011 Jul;29(7):4.
Oral Bisphosphonates and the Risk
of Esophageal Cancer
 Exposure to bisphosphonates may be associated with
an increased risk of esophageal cancer. More studies
are needed to confirm the relationship.
 Aliment Pharmacology Ther. 2012 Oct;36(8):708-16.
doi: 10.1111/apt.12041. Epub 2012 Sep 11.
Bisphosphonate Use and
Gastrointestinal Tract Cancer Risk
 Oral bisphosphonate use had no significant effect on
gastrointestinal cancer risk. However, this finding
should be validated in randomized controlled trials
with long-term follow-up.
 World J Gastroenterology 2012 Oct 28;18(40):5779-88.
doi: 10.3748/wjg.v18.i40.5779.
Prolia (Denusomab)
 Prolia( denosumab)fully human monoclonal antibody
denosumab inhibits osteoclast development, function,
and survival
 Inhibits the RANKL protein that acts as the primary
signal for bone removal
SERMS
 Viviant(bazedoxifene) and Evista(raloxifene) are oral
selective estrogen receptor modulators (SERM) that
have estrogenic actions on bone and anti-estrogenic
actions on the uterus and breast.
 Estrogen is responsible for increased BMD
Forteo
 Forteo( teriparatide) parathyroid hormone analogue
 PTH increases serum calcium, partially accomplishing
this by increasing bone resorption. Thus, chronically
elevated PTH will deplete bone stores. However,
intermittent exposure to PTH will activate osteoblasts
more than osteoclasts. Thus, once-daily injections of
teriparatide have a net effect of stimulating new bone
formation leading to increased bone mineral density
Tylenol VS NSAIDs which is better
 They both work well
 But avoid NSAIDs in older patients due to kidney and
GI concerns.
 Avoid in diabetics and renal patients.
 Contraindicated in pregnancy
RED FLAGS
 Shortness of breath
 BP above 200/100
 Wheezing that doesn’t resolve after two puffs of
albuterol
 Cirrhosis patients
 Patients on amiodarone do not give epi
 Transplant patients do not give motrin or
erythromycin
Red Flags
 MI in the last 6 months
 Pregnant patients are not red flags