A healthy 51-year-old patient who takes medications to treat bipolar disorder requires sedation for two crowns and fillings. A DOCS Education member double-checks his protocol with faculty members, Drs. Jerome Wellbrock and Anthony S. Feck. The member wonders if the patient should stop taking her prescriptions for the sedation appointment.
A DOCS Education Member asks:
I have a 51-year-old female patient who is allergic to sulfa drugs and penicillin. She is very nervous and needs two crowns and fillings.
She is taking ziprasidone 60 mg every evening and bupropion XL 150 mg (3 tablets) in the morning.
I will be using anesthetic without epi as the bupropion blocks uptake of norepi.
How do I move forward with this patient?
DOCS Education faculty member, Dr. Jerome Wellbrock, responds:
It would be helpful to have more detailed information on this patient, including height and weight, BMI, ASA classification, airway classification, sleep habits (snoring, OSA), date of last physical exam and results, tobacco and/or alcohol use, herbals or recreational drug use and vital signs at your pre-sedation evaluation and work up.
Your medication interactions are all a "C" except for the ziprasidone and hydroxyzine which is a "D" interaction with increased risk of prolonged QT interval. Local anesthesia is not really a problem. I would use an incremental protocol with diazepam the night before and triazolam the day of the appointment. I would skip the hydroxyzine unless there is a strong indication for it, such as smoking or nasal congestion.
Dose low and go slow while closely monitoring your patient.
Member follows up with more questions:
Should she stop taking the ziprasidone the night before and the bupropion the day of?
And to answer your questions she is otherwise a healthy, non-smoker with a BMI wnl and no apnea.
What do you mean by incremental for diazepam? It's been a while since I've taken the introductory course and don't remember there being incremental dosing. It was 5, 10 or 20 mg the night before.
DOCS Education faculty member, Dr. Anthony S. Feck, responds:
Diazepam is only given in a single dose of 0.125 -10 mg the night before in patients who are older than 65, or not taking three or more CNS depressants, or not taking a sleep aid drug for insomnia, or do not have to drive themselves to the appointment, or do not have a "D" interaction with it.
Dr. Wellbrock responds:
I would not change the patient's normal medication schedule.
I don't see local anesthetic as a problem. Even though we refer to an "Incremental Protocol" only one sedation drug is incrementally dosed and that is either triazolam or lorazepam. The night before if diazepam is given, it is only given once. The same goes for hydroxyzine the day of appointment—it is only given once.
Be sure to calculate Top Dose for the triazolam or lorazepam for your patient before the appointment and do not exceed Top Dose.
Dr. Feck responds:
Never have patients discontinue any medication they have been prescribed to control a medical condition. So, the answer to your question is no.
The information contained in this, or any case study post in Incisor should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 106 Lenora Street, Seattle, WA 98121. Please print a copy of this posting and include it with your question or request.
