What Protocol Changes to Make for a Patient Taking Daily Benzodiazepines?

Patients with severe dental anxiety may not only be afraid of the dentist. How do we modify the DOCS Education protocols for patients who are already on medication for chronic anxiety?

A DOCS Education member asks:

I have a 24 year-old female with severe anxiety disorder who takes 10mg Zyprexa (olanzapine) nightly, 2mg of Klonopin each morning, and again before bed. Additionally, she only weighs about 95 pounds. Should I plan on her taking her routine meds at night without the addition of or replacement with valium? Given how petite she is, I would normally consider halving the pre-op triazolam dose, but because she takes benzos daily, and because I was planning on having her skip the Klonopin in the morning, I'm concerned a half-dose won't be enough. Any recommendations?

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

I recommend having the patient take all her meds as usual at their usual times. I would not have the patient take any valium the night before, nor triazolam prior to arriving at the office. I would assess her upon arrival, and dose sedative medications in the office appropriately. Given the patient's size, her anxiety, and the likely tolerance to CNS depressants that she has built up, I predict the patient will hypo-respond. Substituting diazepam, or a conservative dose of triazolam, for her existing meds will likely not address the patient's anxiety better than her existing meds.

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