Is it Safe to Sedate a Bipolar, Diabetic Smoker with Active Hep. C?

A clinician has a patient who needs six extractions and has high anxiety. Sounds simple, right?

She's also a bipolar, diabetic smoker with an active HCV infection and liver damage. Not so simple. What sedation medications can she take, if any? Drs. Wellbrock and Goyal advise.

A DOCS Education Member inquires:

I have a 52-year-old female patient with active DM2, bipolar disorder, peripheral neuropathy, hyperlipidemia, active HCV infection, F4 per FibroScan®, FIB 4-2.85, MELD score of 7, and Child-Pugh score of 5. And she is a smoker.

What medications can I administer to safely sedate her? She has high anxiety and needs her remaining six teeth extracted. This will not be a long procedure, but I want her to be comfortable.

Dr. Jerome Wellbrock, DOCS Education faculty member, responds:

Thank you for posting about such an interesting case. I certainly hope that both Dr. Goyal and Dr. Fang post additional replies.

I think there are several red flags here. My first thought is that I would not want to sedate this patient in my office; I would prefer to see her in a setting where an anesthesiologist takes care of the sedation while I do the dentistry. You need to know both the severity of her diabetes (peripheral neuropathy) and her level of control, i.e. get a current HA1c. A FibroScan result of F4 indicates either cirrhosis or severe liver fibrosis; her MELD (Model for End-Stage Liver Disease) score of 7 and a Child-Pugh score of 5 indicate the severity of her liver disease and mortality risk. She looks like a Child-Pugh class A with an expected one-year survival of 100 percent and a two-year survival of 85 percent.

Overall, you have a bipolar, diabetic smoker with active liver disease with resultant damage. It would be helpful if you provided information about her current medical treatments or medications. Do you think bleeding will be an issue?

The member follows up:

I had a brief discussion with her PCP. Her doctor reports that there is no kidney disease or damage, and that she would classify her liver disease as mild. Her hepatitis C is active and she is not currently in treatment. Additionally, her HA1c is 6.8 and her platelet count is 151,000. Her current medications include: metformin 1000 mg 2x daily, lamotrigine 100 mg 1x daily, quetiapine 300 mg 2 tabs at bedtime, simvastatin 40 mg 1x daily, and lisinopril 10 mg 1 tab daily.

I hope this new information helps to complete the picture. I look forward to hearing back.

Dr. Wellbrock responds:

Thanks for the additional information. It looks like you should be a go for oral sedation. The Lexicomp drug interaction analysis shows most of the interactions to be a "C" and only the Seroquel® (quetiapine) and hydroxyzine to be a "D" interaction. Since she is a smoker, I would still add hydroxyzine to my protocol.

Dr. PJ Goyal, DOCS Education faculty member, responds:

I would classify this patient as an ASA III+. I do not think her liver concerns will have any effect on oral sedation medications, but I always proceed with caution when I see a combination of medical issues. I think a short appointment with an anxiolytic and the patient will be fine.

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