Questioning doctor
My 60-year-old patient takes the following medications: sumatriptan, hydrochlorothiazide, metoprolol, valacyclovir, sildenafil, doxazosin, losartan, quinapril, and verapamil.
His health history lists only high blood pressure as a medical concern which is now controlled. The “Medical Consult for Dental Services†form was completed by his physician who cleared him for a planned procedure likely to take 5 or 6 hours. He approved him for all of the medications in our arsenal including the local anesthetics (Septocaine® with epi or lidocaine with epi).
The primary reason the patient is requesting sedation is on account of severe gagging. However, when I ran all of his medications plus our sedation options through the Lexi-Comp interactions analysis, I discovered a large number of Category D risk ratings. These included verapamil reacting with diazepam and triazolam as well as metoprolol reacting with Septocaine® and lidocaine.
I am concerned with all of the medications and interactions. Could you give me advice on how to properly treat this patient?
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
Due to his complicated hypertension (over four medications to control a medical condition) I would place this patient in the ASA III category and insist upon a recent medical evaluation—one within the last six months.
As for the medical consultation I prefer to look at it as a source of information rather than permission or clearance. We ultimately take responsibility for the decision to treat our patients.
You have done your homework with regard to drug interactions. We wouldn’t want to use diazepam or triazolam with this patient. However, we can use lorazepam and hydroxyzine. That means no sedation medication the night before and an incremental protocol using a lorazepam loading dose, with assessment upon arrival in which a single dose of hydroxyzine and incremental doses of lorazepam can be given according to the appropriate protocol.
As far as the local anesthetic regimen, use lidocaine and Septocaine® with epinephrine slowly and judiciously, monitoring your patient closely.
Given the patient’s severe gag response, hydroxyzine becomes a more integral part of the sedation regimen. Also, I recommend a test sedation appointment rather than one lasting 5 or 6 hours so that you can determine whether sedation will overcome the gag response enough to allow treatment.
Dr. Leslie Fang, DOCS Education Faculty responds:
I would also classify this as an ASA III patient.
His blood pressure would seem to be difficult to control, given the fact that he is on
hydrochlorothiazide (a diuretic)
doxazosin (a vasodilator)
losartan (an ARB)
quinapril (an ACE inhibitor)
metoprolol (a beta blocker)
verapamil (a calcium channel blocker)
Actually, there isn’t a single class of anti-hypertensive he ISN’T on. So his blood pressure must be monitored very closely.
With verapamil on board, you can’t use diazepam or triazolam and have to resort to lorazepam/hydroxyzine protocol. Don’t be surprised by liability of blood pressure during the case.
