Sedation of 67-Year-Old Woman Taking Anxiolytic Medication

A DOCS Education Member asks:

Hello,
I have a new patient, and below is my thought process. Please critique, and let me know if you advise something different.
Thank you!

Please note that this patient has not been seen yet for a proper workup: I saw patient only for a “free consultation” up to this point and as such baseline vitals are not available.

She is a 67–year–-old female of average weight (I did not take height, weight, or BMI yet) female who meets the “rule of 4” with regards to medications: she is on 4. She has general dental anxiety, and requires a difficult extraction of tooth #3. The appointment is expected to be 2 hours or less.

  • Buspar (buspirone) 10mg, bid for anxiety
    • Used mainly to treat GAD (Generalized Anxiety Disorder)
    • Central acting
    • Pharmacology is NOT related to benzodiazepines (not a GABA receptor agonist)
    • Metabolized mainly by liver, slightly by kidney
  • Remeron (mirtazapine) 15 mg, qd for anxiety and sleep
    • Mechanism is unknown, but believed to enhance central noradrenergic and serotonergic activity
    • Potent antagonist of H1 receptors, which may explain sedative effects
  • Benicar 40mg, qd for hypertension
  • Ursodiol 500mg bid for autoimmune biliary cirrhosis of the liver (non-alcohol related)

Preliminary Protocol evaluation:

  • Night-before Diazepam: NO! SKIP!!
  • Insomnia drug at betime (Remeron). Refer to page V–4 of DOCS NYU manual.
  • Same page of manual:
    • “If 2 CNS depressants / day, use 2.5mg diazepam”
    • I still say skip the diazepam, due to insomnia drug above.
  • Triazolam 0.125mg:
    • 1 pill at 7am.
  • Arrive at office at 8am. Assess patient. Take vitals. If needed, provide second pill. Let pt sit. Assess.
    • If ready, administer nitrous, administer local anesthetic.

    Dr. Tony Feck, DOCS Education Dean of Faculty, responds:

    I appreciate the thought and homework that went into your inquiry. Well done! My critiques:

    1. The rule of 4 says that if 4 or more medications are used to treat the same medical condition, that medical condition is more fragile (more challenging to control, and therefore more likely to become out of control when challenged — e.g. stress).
    2. Buspar's pharmacology is related to that of the benzodiazepines in that they are both CNS depressants. Therefore the potential exists for both potentiating CNS depression or cross-tolerance. It’s more accurate to say, Buspar's pharmacodynamics are not the same as those of the benzodiazepines.
    3. Since the Remeron is being used as a sleep aid prior to sleep, I would not use diazepam the night before. Even if the patient was not taking the Remeron, I would not use diazepam the night before due to the patient's age.
    4. I agree with your loading dose of triazolam.

    Of course you will need a comprehensive evaluation of the patient prior to final consideration of the candidate for sedation. Again, well planned!

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