A member of DOCS Education writes:
I have a 55 year old female being treated for central adrenal insufficiency, multiple sclerosis, hypertension, hypercholesterolemia, ADD, hypothyroidism and hormone replacement therapy. All are well controlled at this time. Her physician has recommended tripling her dose of Cortef® the day of surgery. She has been a patient for years and is very relaxed in the chair, even for long appointments.
- These are the daily meds she is taking:
- (Cholesterol) Simvastatin 10 mgs
- (Hypertension) Hydrochlorothiazide 25 mgs
- (MS) Copaxone® 20 mgs/ ml injectable
- (Hypothyroidism) Levoxyl®112 mcg
- (SSRI) Cymbalta® 60 mg
- (ADD)Provigil® 100 mg bid
- (Steroid) Cortef® 15 mgs AM/ 10 mgs PM
- Vitamin D 1000 units
- Iron 325 mg
- (HRT) DHEA caps (Prasterone) 50
- Cranberry Caps
- I have scheduled a morning appointment for her and planned to use the following protocol:
- Valium® 10 mgs PO night before
- Lorazepam 2mgs PO beginning of appointment
- Hydroxyzine 30 mgs PO beginning of appointment
I considered multiple doses of Triazolam preop 0.25 mgs PO and 0.25 mgs SL start of the appointment, and more as needed. I have had good results with Lorazepam even though the onset seems long, I schedule the time into the appointment to account for this waiting period.
I usually plan on an hour at the end of an appointment like this one to be sure the patient is stable and bleeding is not excessive.
Extraction of her remaining upper teeth (12) and 5 lower teeth with socket preservation and insertion of an immediate upper denture are the planned procedures for this visit.
I could use some input on this case. Thanks.
Dr. Lesley Fang, Medical Director of DOCS Education Faculty, responds:
This is obviously a complicated case, I have two pieces of advice:
First, while you’ve stated that the patient is on Copaxone® and that the medication is controlling her multiple sclerosis, I would like you to confirm this with her neurologist.
Secondly, the cause of her adrenal insufficeiency remains unclear to me. One supposition is that she has developed adrenal insufficiency as a result of long term steroid use. However, the steroid replacement regimen is more compatible with complete adrenal insufficiency, either because of adrenal failure, as with Addison's, or pituitary failure to produce ACTH. You definitely need to know the cause.
If it is, in fact, adrenal insufficiency, there is both corticosteroid deficiency and mineralocorticoid insufficiency, which can make the patient much more susceptible to hypotension, particularly with sedation. If this is due to pituitary disease, it may be the reason for her hypothyroidism.
In short, you need to better define the cause of the adrenal insufficiency before you proceed.
Dr. Feck will assist you with your sedation options, but I would consider this an ASA 3/4 patient.
Dr. Anthony Feck, Dean of DOCS Education Faculty, adds:
When I thought I could no longer be impressed by Dr. Fang, he surprises me once more. What a resource and benefit he is to the DOCS membership.
While your proposed protocol is doable, I recommend a triazolam or triazolam/hydroxyzine protocol for a few reasons. When doing incremental dosing, triazolam is the sedation drug of choice. It is better suited for stacked dosing compared to a drug like lorazepam which has a slower onset of action, a longer duration of action and a longer half-life. Secondly, triazolam is a more efficacious sedative than lorazepam, which is something that may come in handy on a patient taking Provigil®.
The member returns:
Dr. Feck, I consider it a HUGE benefit to have access to the likes of both you and Dr. Fang, both as lecturers and advisors. It is constant education, safer for patients and safer for providers. Thank you so much
