A member of DOCS Education writes:
I have scheduled a 58-year-old male for full upper arch restorations. He is a chronic pain patient due to fibromyalgia and migraines. The patient’s medications include:
- Oxycontin™ 10 mg
- Lamotrigine 300 mg
- Dexilant™ 60 mg
- Sonata™ 20 mg
- Triazolam 0.125 mg
- Lexapro™ 2.5 mg
- Levoxyl 0.125 mg
Since the procedure will take at least four hours I had planned on using 10 mg of diazepam the night before and 2 mg lorazepam one hour before. Should I modify this protocol? I live in California and am licensed to administer incremental doses. Since the patient takes triazolam most nights I wasn't sure how effective lorazepam would be for a long appointment.
Dr. Anthony Feck, Dean of DOCS Education Faculty, responds:
This is a tough case for oral conscious sedation protocols. I believe the case is made for IV sedation, where there is no TOP Dose and the patient can be titrated to effect using sedatives and analgesics.
If you're going to try this with oral medications anyway, manage the patient's expectations (and yours). Try a test sedation appointment before you schedule a four-hour appointment. This patient has not only built up tolerance to CNS depressants, but specifically to medications in the class of which we use in our sedation protocols.
I wouldn't use any diazepam the night before. I like the idea of using triazolam with this patient (since you can incrementally dose) plus hydroxyzine. I know that he is already taking triazolam, but in a low dose, and triazolam is more efficacious than is lorazepam. The lorazepam also has a longer half-life: since this patient is already taking CNS depressants, there is greater risk. Your loading dose of triazolam should be 0.25 mg, and assess upon arrival for additional medication plus a single dose of hydroxyzine. Dose appropriately at proper intervals and stay within the patient's TOP Dose.