Common medical conditions and prescribed drugs常見疾病和處方藥

1、Common Medical Conditions and Prescribed DrugsAnders Nattestad1Achieve a basic understanding of medical conditions and drugs relevant to dentistryMake evidence-based decision of use of drugs in dentistryLearning outcomes2HYCD/APAPLipitorNorvascToprol XLSynthroidZoloftAmoxicillinLexaproAlbuterolZocor

2、The Top 30 Prescription Drugs in USNexiumLevothyroxineAmbienSingulairPrevacidPlavixZithromaxFosamaxZyrtecAdvair diskusProtonixFurosemideAtenololEffexorWarfarinCephalexinFlonaseOxycodone/APAPLevaquinDiovan3A drug can be characterized byIts salesname (for example Coumadin)The actual drug (in this exam

3、ple: Warfarin)Its pharmacological category (in this example: Anticoagulant, Coumarin Derivative)Of these three pieces of information, the most important one is the pharmacological categoryDrug names, generics and categories4AnticoagulantCoumarin Derivative (Coumadin/warfarin)Antiplatelet agent (Plav

4、ix/Clopidogrel)Salicylate (Aspirin/Acetylsalicylic Acid)AntihypertensiveBeta 1 blocker (Atenolol)Calcium channel blocker (Norvasc/Amlodipine)ACE inhibitor (Lisinopril) or ARB (Cozaar)Diuretics (Hydroclorothiazide (HCTZ)Anti-anxietyBenzodiazapines (Valium/Diazepam or better Xanax/Alprazolam)Nonbenzod

5、iazepine Anxiolytics and Hypnotics (Diphenhydramine)Barbiturates (Pentobarbital)Main and minor drug category examplesDrug categories: /cder/handbook/category.htm5Overall recommendation/Guidelineson medically complex patientsMedical HxPhysical evaluationVital signsLab examsTx planningTxMonitoring dur

6、ing txPost-medicationFollow-upPre-medicationRefer pt outMedical consult6Overall recommendationsDo not be intimidated by a complex medical history and a very long list of drugsTake one disease and one drug at the timeUse Dr. Jacobsens document:/docs/patientProtocol/Medically_Complex.pdfAsk for advice

7、 when needed andOverall recommendation/Guidelineson medically complex patients7Medical consult?And sometimes it is better not to ask!8AMI in the last monthsStroke in the last monthsUncontrollered non-compliant diabeticsBlood pressure above 180/110*HIV/AIDS with CD4 50* and/or platelet count 3.5* and

8、 need tx with bleeding such as extractionsUndiagnosed and untreated chest painElective tx should be consideredpostponed in patients with *Individual assessment of the patient is necessary do not treat numbers treat patientsMedical HxPhysical evaluationVital signsLab examsTx planningTxMonitoring duri

9、ng txPost-medicationFollow-upPre-medicationRefer pt outMedical consult938 year old Caucasian female Chief complaint: I need the rest of my teeth removed and get denturesMed Hx: Previous IV drug abuseArtificial heart valves placed in 2001 due to endocarditis HTNMedications: Methadone, Norvasc, Atenol

10、ol, Ambien and CoumadinVital signs: BP 176/80, pulse 105Pt. is very anxiousCase 110Endocarditis and artificial heart valves?11Guidelines - Prophylactic use of antibiotics12Antibiotics: Development of resistenceVertical13Antibiotics development of resistanceMovement of genetic material from one strai

11、n of bacteria to another by transduktion, transformation eller konjugation (horisontal)It is estimated that 200.000 people dies in the US annually from hospital infections (nosocomial)14New guidelines for prophylactic antibiotics (CVD only)AHA and ADA:“For decades, the American Heart Association (AH

12、A) recommended that patients with certain heart conditions take antibiotics shortly before dental treatment. This was done with the belief that antibiotics would prevent infective endocarditis. The AHA recommends that most of these patients no longer need short-term antibiotics as a preventive measu

13、re before their dental treatment”15/prof/resources/topics/infective_endocarditis.asp 4/19/07Reasons for new guidelinesIE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental, GI tract or GU tract procedure

14、Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who undergo a dental, GI tract, or GU tract procedureThe risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapyMaintenance of optimal oral health and hyg

15、iene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE.16RecommendationsProsthetic cardiac valvePrevious infective endocarditisCongenital heart disease (CHD), but only whenUnrepaired cyanot

16、ic CHD, including palliative shunts and conduitsCompletely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedureRepaired CHD with residual defects at the site or adjacent to the site

17、 of a prosthetic patch or prosthetic device (which inhibit endothelialization)Cardiac transplantation recipients who develop cardiac valvulopathy17Cardiac Conditions Associated with the Highest Risk of Adverse Outcome from Endocarditis for Which Prophylaxis with Dental Procedures Is Recommended:Thus

18、 no antibiotic prophylactics is recommended forHeart murmurHypertrofic obstructive cardiomyopathyRheumatic heart feverMitral valve surgeryCatheter in the right side of the heartIdiopathic hypertrofic aorta stenosisOsteogenesis imperfectaSevere arteriosclerosis18Which patients have increased bleeding

19、 tendencyInborn increased bleeding tendency, ie von Willebrands disease and hemofiliaDeveloped because of disease, ie. thrombocytopeniaAcquired because of medication:Antiocoagulant treatment (vit. K antagonist and LMWH (Low Molecular Weight Heparins)Thrombocyte antagonists (ASA)19Diseases associated

20、 with thrombosis20What diseases are treated with ACTBypass surgery with an implant in aortaInsertion of artificial heart valvesPrevious history of thrombosisPrevious history of MIAtrial dysrhythmias = nervous heart2122AnticoagulantsWhat drugs are used and how do they workHeparinsInhibits the transit

21、ion of fibrinogen to fibrin and delays the formation of thrombin from prothrombin by interfering with the activity of thromboplastin. In addition, it inhibits the aggregation of platelets.Was previously only used in a hospital setting, but new mini-heparins (LMWH) is increasingly used on an outpatie

22、nt basisWarfarin (Coumadin)Works indirectly by inducing vitamin-K deficiency, which depresses hepatic synthesis of coagulation factors (II, VII, IX, X), which are vitamin KdependentPlavixThienopyridine antiplatelet agent (adenosine diphosphate (ADP)-receptor antagonist). Works by inhibiting platelet

23、 aggregation. Aspirin (ASA)ASA has a mild anti-thrombotic effect by permanently inhibiting the aggregation of plateletsRivaroxaban (Xarelto)Specific Xa clotting factor inhibitorConcerns over internal bleeding 23How is the coagulation measured?The previous measure was PT, but it was not sufficiently

24、reproducableNow most use INR (International Normalized Ratio)INR = (PTpatient/PTnormal)ISI ISI is an International Sensitivity IndexINR is normally 1 and the therapeutical level is between 2 and 3,5 depending on which disease is causing the treatmentINR does not measure anti-coagulation by the new m

25、ini-heparins (perhaps these are not yet FDA approved)24Traditional guidelinesAvoid using aspirin, NSAID og corticosteroidsGet the INR measured on the morning of a planned major bleeding treatmentThe warfarin is reduced or stopped a few days prior to the bleeding treatment and resumed on the followin

26、g evening. Normally the INR will be reduced by 0.5-1 per day when warfarin is stopped.The INR must be below 1,725New information26New information27New information28New information29Alternative measures to secure hemostasisUse all local measures includingRemoval of granulation tissuePlace an absorbab

27、le gelatin sponge with hemostatic agent (Surgicel)Suture after extraction Let patient rinse with tranexamic acid 5% for two minutes several times dailyIf all other failes, refer to hospital where Vit. K can be given if indicated (Pts on Coumadin)30Figure 8 suture of extraction socket1231Revised guid

28、elinesGet the INR measured when relevantAvoid interfering with ACT (Warfarin) treatment. The risk of local bleeding complications is negliable compared to the risk that the patient may experience an MI or deep venous trombsisBe aware the MDs may not be up-to-date on thisUse all local measures to sec

29、ure hemostasisNever let the patient leave the clinic bleeding32February 2016 incident reported in CDAJHypertension (HTN) or high blood pressure, sometimes called arterial hypertension, is a chronic medical condition in which the blood pressure in the arteries is elevatedHypertension is defined as a

30、systolic pressure above 140 and/or diastolic above 90In most patients the increase is due to increased peripheral resistance of the vascular system not an increase in cardiac outputIn some elderly people, the systolic is high, but the diastolic is normal. This is called isolated systolic hypertensio

31、n. This high pulse pressure in elderly people is explained by increased arterial stiffnessHypertension can be managed with lifestyle modifications or medicineWhat is hypertension?341 out of 6 have hypertension with no symptoms, but have 3-4 times increase in risk of cardiovascular diseaseStudies est

32、imate that 1 more patient out of 11 with hypertension over a 10-year period would survive a cardiovascular event if their hypertension was recognized and treated A busy practice may see 1,500 patients per year 250 will have hypertension and not know. This correlates to saving the life of 2-3 patient

33、s per yearRemember that asymptomatic patients are unlikely to see their physcician, but they usually will go and see you regularlyWhy screen for hypertension?3536Gold Standard37Automated devices for BP measurement$40 on AmazonX/ora/compliance_ref/cpg/cpgdev/cpg310-210.htmlAAMI Criteria for accuracy

34、is 3 mm Hg or +/- 2% of reading (whichever is greater) Upper armWristSystolicThe top number, which is also the higher of the two numbers, measures the pressure in the arteries when the heart beats (when the heart muscle contracts). It is thus a measure of heart contractility as a response to oxygen

35、needDiastolicThe bottom number, which is also the lower of the two numbers, measures the pressure in the arteries between heartbeats (when the heart muscle is resting between beats and refilling with blood). This is a measure of peripheral resistanceWhat does the systolic and diastolic numbers actua

36、lly mean?38Calcium channel blocker (Amlodipine)This drug prevents calcium from entering the smooth muscle cells of the heart and arteries. When calcium enters these cells, it causes a stronger and harder contraction, so by decreasing the calcium, the hearts contraction is not as forceful. Calcium ch

37、annel blockers relax and open up narrowed blood vessels, reduce heart rate and lower blood pressureDiuretics (Hydroclorothiazide (HCTZ)Diuretics help the body get rid of excess sodium (salt) and water and help control blood pressure. They are often used in combination with additional prescription th

38、erapies create need for monitoring electrolyte balanceACE inhibitor (Lisinopril)Angiotensin is a chemical that causes the arteries to become narrow, especially in the kidneys but also throughout the body. ACE stands for Angiotensin-converting enzyme. ACE inhibitors help the body produce less angiote

39、nsin, which helps the blood vessels relax and open up, which, in turn, lowers blood pressure39Medications for hypertension3 lines on 16 page package insert477,000 hits on googleARB is a good alternative and it is now generic (Cozaar)40Lisinopril and coughARB Angiotension receptor blockers (Cozaar)Th

40、ese drugs block the effects of angiotensin, a chemical that causes the arteries to become narrow. Angiotensin needs a receptor- like a chemical slot to fit into or bind with- in order to constrict the blood vessel. ARBs block the receptors so the angiotensin fails to constrict the blood vessel. This

41、 means blood vessels stay open and blood pressure is reducedBeta 1 blocker (Atenolol)Beta-blockers reduce the heart rate, the hearts workload and the hearts output of blood, which lowers blood pressure. This is not “free” beta blockers are reducing the oxygen supply in this “on-demand” system41Medic

42、ations for hypertension65 year old African American femaleChief complaint: Loose and painful teeth in all four quadrantsMed Hx: Had both knees replaced with total jointsMedications: NoneCase 24243Total joint replacementWatters W 3rd et al. Prevention of Orthopaedic Implant Infection in Patients Unde

43、rgoing Dental Procedures. J Am Acad Orthop Surg. 2013 Mar;21(3):180-9444530-year old Caucasian female7 months pregnantChief complaint: Pain and swelling around lower right molar. In the last hours felt difficulty swallowing. Pain is 9 on a scale from 0 to 10.Med Hx: Otherwise non contributoryVitals:

44、 All wnl except temperature is 103Case 34647Spread of infection to floor of mouth48Spread of infection to floor of mouth49What is wrong?An odontogenic infection of periapical origin due to caries and pulp necrosis in tooth no. 19 spreading into the floor of the mouthLudwigs anginaContraindications i

45、n pregnancyOrgan systemsCardiovascular systemHematological systemRespiratory systemGastrointestinal systemGenitourinary systemConsiderationsLocal anestheticsGeneral anestheticsAntibioticsAnalgeticsHypnotics50FDA Pregnancy risk categoriesA - Controlled studies in women fail to demonstrate a risk to t

46、he fetus in the first trimester, and thepossibility of fetal harm appears remote.B - Animal studies do not indicate a risk to the fetus and there are no controlled human studies, oranimal studies do show an adverse effect on the fetus but well-controlled studies in pregnantwomen have Wed to demonstr

47、ate a risk to the fetus.C - Studies have shown that the drug exerts animal teratogenic or embryocidal effects, but thereare no controlled studies in women, or no studies are available in either animals or women.D - Positive evidence of human fetal risk exists, but benefits in certain situations (e.g

48、., lifethreateningsituations or serious diseases for which safer drugs cannot be used or are ineffective)may make use of the drug acceptable despite its risks.X - Studies in animals or humans have demonstrated fetal abnormalities or there is evidence offetal risk based on human experience, or both,

49、and the risk dearly outweighs any possible benefit.SafeUnsafeThink twice51Pregnancy and pain medicationsGeneric nameBrand Names Risk categoryAcetaminophen Tylenol, Anacin-3, Dapa BAcetylsalicylic acid AspirinB (D3rd trimester) Ibuprofen Advil, Nuprin, Motrin DNaproxen Daprox, Naprosyn CCodeineCodein

50、e (+ combinations)CCox-2 inhibitorsVioxx, CelebrexC1st choice*As with any medication during pregnancy: Only if absolutely necessary?52Pregnancy and antibioticsGeneric name Risk categoryPenicillin BCephalosporins BMacrolides B (Erythromycin, Azithromycin)C (Clarithromycin, Biaxin)Aminoglycosides C (G

51、entamycin) D (Streptomycin)TetracyclinDVancomycinCMetronidazoleBClindamycinB1st choice*Any medication during pregnancy: Only if absolutely necessary53?65-year old Caucasian femaleChief complaint: Throbbing pain in #30 for three daysMed Hx: Chronic back pain after car accident three year agoMedicatio

52、nsPercocet 10 mg x2 qidTofranil (Imipramine) 300 mg bidCase 454Tricyclic antidepressants5556Oxycodone dependency57NY Times - December 27, 2005 “Lately, she has been playing with one of the strongest opiates and potentially addictive painkillers ever created, Oxycontin. She downs a few with a single

53、shot of vodka and calls the combination the sorority girls diet cocktail, because it simultaneously allows for a stronger kick of inebriation and far fewer calories than mere alcohol alone.”“The most recent Monitoring the Future report, the continuing study of teenage drug use conducted by the Unive

54、rsity of Michigan and the National Institutes of Drug Abuse since 1975, found that 5.5 percent of all high school seniors abused Oxycontin, up from 4 percent in 2002. Oxycontin abuse has increased 26 percent since 2002 among 8th, 9th and 12th graders.“Teens abuse prescription drugs more than any oth

55、er illicit street drug except marijuana”58596072-year old Caucasian maleChief complaint: Pain from the lower left mandible where a tooth was extracted two months agoMed Hx: Pt. was diagnosed with multiple myeloma 6 months agoMedications: Zometa is given as IV injections every 3rd week since the diag

56、nosisCase 561Bisphosphonates and BRONJ62Relative Potency and risk of BPsOral administration Potency RiskEtidronate (Didronel)1Tiludronate (Skelide)10Pamidronate (Aredia)100Alendronate (Fosamax)1,0000.1-0.3%Risedronate (Actonel) 10,000Oral and IV administrationIbandronate (Boniva)10,000IV administrat

57、ionZolendronic acid (Zometa)100,0000.8-12%63Dental exam (screening) before use of IV bisphosphonates (just like with radiation therapy)Avoid elective surgery for patients on or off IV bisphosphonates such as dental implantsIf patients have been taking oral bisphosphonates for less than 3 years, disc

58、ontinuation of oral bisphosphonates for a period of 3 months prior to and 3 months after elective invasive dental may lower the risk of BRONJClinical consequences of BPsAAOMS Position paper on BONJ - J Oral Maxillofac Surg 65:369-376, 200764Surgeon General Report (2004)40% of American women 50 yo. w

59、ill experience an osteoporotic fracture13% of men 50 yo.By 2020 it is estimated that 50% of all Americans over the age of 50 will be at risk of developing osteoporosisDirect cost expenditures for 1.3 million fractures per yr = $14 billion +Osteoporosis is a BIG problem in the USA!65Body JJ, et al. P

60、ain 2004;111:30612Long-term relief of metastaticbone pain with oral IbandronateMean change in pain scorefrom baseline0.30.20.100.10.20.3Time (weeks)01224364860728496p=0.001PlaceboIbandronate 50mg24% reduction6621 year old Caucasian male is reporting pain on lower right, where the is a significant sw