A member of DOCS Education writes:
I have a 55-year-old female anxious patient. She has chronic obstructive pulmonary disease (COPD) due to second-hand smoke. I would classify her as an ASA III patient. Major concerns are the medications she takes for this condition. I am listing these for possible interactions or other issues I need to be aware of in her situation.
- COPD medications:
- One Singulair® at bedtime
- QVAR® Inhaler four times a day - beclomethasone steroid maintenance
- Atrovent Inhaler two times a day - bronchodilater for COPD/emphysema
- Albuterol solution used in nebulizer four times a day
- Diabetes:
- Metformin - 1000 mg twice a day
- Pain:
- Hydrocodone 10/325 (half in the morning, half in the evening and one at bedtime) for spinal stenosis and back injury
- The following medications are not taken regularly:
- Back and muscle spasms: tizanidine 4 mg (once in the morning, once in the evening) and 8 mg at bedtime. 16 mg total per day
- Anti-inflammatory: Celebrex® 200 mg (once in the morning, once in the evening) and one at bedtime. 600 mg total per day
- Anti-anxiety: lorazepam 1 mg; (half in the morning, half in the evening), and one at bedtime. Patient usually only takes one as needed
- Sleep aid: zolpidem 10 mg at bedtime. Patient takes this every night.
This patient desires oral conscious sedation; however, I am worried about her drug interactions and would appreciate some feedback. I have concerns for bleeding due to Celebrex® and am debating instructing her to stop these for two days prior to her appointment. I plan to have her continue taking the rest of her medications, bringing her own inhalers to the office on the day of treatment. I would have her take the zolpidem the night prior as well as her metformin with a light breakfast the morning of her appointment.
Since she takes lorazepam and desires more amnesia effect, I would use triazolam for her initial dose of 0.5 mg orally one hour prior to the appointment. She would be evaluated from there. With her COPD meds would it be helpful or contraindicated to add hydroxyzine? After evaluation I would want to incrementally dose along with N2O as needed. Of course my major concern remains her COPD meds.
Dr. Lesley Fang, Medical Director of DOCS Education Faculty, responds:
As you have correctly identified, the patient is on a litany of medications for her COPD and is ASA III. You need to know if she retains CO2. If she does, she is not a sedation candidate.
Next there is the issue of diabetes. Please remember to use the diabetes protocols when sedating this patient. You must also be aware that there is not an inconsequential amount of sedatives in her system already, and it is important to proceed with caution. Your patient is taking three times the maximum daily dose of Celebrex®—in addition to hydrocodone and muscle relaxants. Celebrex® does not have an anti-platelet effect. Therefore your patient may continue with her routine dosages, but it is important to note that with these particular medications she will be more difficult to sedate if she is in pain. Finally I would not use hydroxyzine with this patient as drying up the airway may induce bronchospasm.
These notes aside, this is a very nice assessment of your case.
The DOCS Education member follows-up:
I called her physician to discuss possible C02 retention which her tests did not show. The patient’s physician did not see problems with benzodiazepines as long as it is supported with oxygen.
Dr. Lesley Fang, Medical Director of DOCS Education Faculty, responds:
As I had suspected: while she is taking a lot of medications, she is not over-the-hill COPD.
I agree that she remains an ASA III because of airway concerns but there are no contraindications to oral conscious sedation.
Dr. Jerome Wellbrock, DOCS Education faculty, adds:
I agree you have done a nice job of assessing this patient and provided a great deal of information. Personally I would be very cautious about sedating this patient as I am with any COPD patient. I would expect her to be a hyporesponder and would be concerned about the amount of meds needed to dose over her current meds. If you are comfortable with this patient then definitely dose low and slow and monitor her closely. Don't forget to calculate your top dose and stay clear.
