DRUGS AND DENTISTRY:

New Issues and Newer Solutions!!

Karen A. Baker, MS Pharm.
College of Dentistry
University of Iowa
KA Baker 2016

Table A.1
ANTIHYPERTENSIVE MEDICATIONS SEE DENTAL MANAGEMENT GUIDE

CATEGORY ADVERSE EFFECTS TREATMENT IMPACT

DIURETICS thiazides are used for hypertension and loops are used mostly for Heart Failure and edema

Thiazide-Type
Chlorothiazide (Diuril,G)
Chlorthalidone (Hygroton, G)
Hydrochlorothiazide (Microzide 12.5mg,G)
Indapamide (Lozol)
Methyclothiazide (Enduron, G)
Metolazone (Zaroxolyn, Mykrox)
-All agents can cause igh uric acid, low K+,
high blood sugar, low sodium, slight
xerostomia, oral ulcerations
-Chlorthalidone is becoming the diuretic of
choice for hypertension due to longer duration
and less dependence on renal fx for effect
-Oral lesions possible
-NSAIDs decrease effect of diuretic.
Prostaglandins enhance renal blood flow so
any PG inhibitor can reduce diuretic
effectiveness. Minimize effect by limiting
duration to 3-5 days.

Loop Diuretics
Bumetanide (Bumex,G) Dehydration, low K+, high blood sugar, high -Treat xerostomia
Furosemide (Lasix, G) uric acid, oral lichenoid lesions, most severe -Identify oral ulcers
Torsemide (Demadex) xerostomia of all diuretics -NSAIDs decrease effect of diuretic. Best
choice is Diflunisal.
-Increased gag reflex
Potassium-Sparing
-NSAIDs decrease amiloride effect
Amiloride (Midamor, G) High K+, gastrointestinal upset (GI)
-Concomitant Indomethacin with triamterene
Spironolactone (Aldactone, G)
may cause renal failure. Avoid combo
Triamterene (Dyrenium,G)

Combination Diuretics
Aldactazide (HCTZ + Spironolactone,G) All of these combination diuretics are intended See individual agents above
Dyazide (HCTZ 25 + Triam 37.5, G) to minimize potassium depletion while
Maxzide-25 (HCTZ 25 + Triam 37.5, G) providing good blood pressure reduction
Maxzide (HCTZ 50 + Triam 75, G)
Moduretic (HCTZ + Amiloride, G)

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS-ACE BREAKS DOWN BRADYKININ IN LUNG COUGH

Benazepril (Lotensin,G)
Captopril (Capoten, G) HA, dizziness, fatigue,hypotension, loss of -Oral lesions possible
Enalapril (Vasotec, G) taste, oral ulcers, cough(highest with -NSAIDs decrease effect
Fosinopril (Monopril,G) ramipril with 12% incidence) -Caution with position change
Lisinopril (Prinivil,Zestril,G) -Quinapril reduces Tetracycline absorption by
Moexipril (Univasc,g) Early in therapy, reactions such as orofacial 33%
Perindopril (Aceon) angioedema and scalded mouth syndrome -ACEIs can cause hyperkalemia so patients
Quinapril (Accupril) can occur. Both of these reactions require should avoid salt substitutes which contain
Ramipril (Altace,g) discontinuation of the ACEI with little prospect potassium and cardiac rate and rhythym
Spirapril (Renormax) of successful rechallenge changes should be investigated.
Trandolapril (Mavik,g)

ANGIOTENSIN RECEPTOR BLOCKERS (ARBs)

Azilsartan (Edarbi) HA,dizziness,cough (1%),

Candesartan (Atacand,g) HA, dizziness, cough (1%) -NSAIDs decrease effect

HA, dizziness, cough (2%) -Caution with position change

Eprosartan (Teveten,g)

HA, dizziness, cough (2.8%) -macrolides and azole antifungals may

Irbesartan (Avapro,g) increase losartan levels
Losartan (Cozaar, Hyzaar,g) HA, dizziness, cough (3.4%)
-Well tolerated but more expensive than ACE
HA, dizziness, cough (1%) Inhibitors
Telmisartan (Micardis)
HA, dizziness, cough (1%} -not much hypotension
Valsartan(Diovan,g)

1
kbaker medcomp 03/01/16
CALCIUM CHANNEL BLOCKERS
Amlodipine (Norvasc,g)...................
Bepridil (Vascor)......................
Diltiazem (Cardizem/SR/CD,Dilacor XL,G).
Felodipine (Plendil)....................
Isradipine (DynaCirc)...................
Nicardipine (Cardene)...................
Nifedipine (Procardia XL, Adalat, G)....
Nimodipine (Nimotop,g)....................
Nislodipine (Sular,g)..
Verapamil ...........................
(Calan/SR, Isoptin/SR, Verelan, G)
PERIPHERAL ANTI-ADRENERGIC DRUGS
Beta-Blockers
+Acebutolol (Sectral, G)..................
+Atenolol (Tenormin, G)................
+Betaxolol (Kerlone,G)...................
+Bisoprolol (Zebeta, Ziac w/HCTZ,G)......
++Carteolol (Cartrol)...................
+++Carvedilol (Coreg)*..................
+++Labetalol (Trandate, Normodyne, G).....
+Metoprolol (Lopressor, Toprol XL,G)...
++Nadolol (Corgard,G)...................
+Nebivolol (Bystolic).
++Penbutolol (Levatol)..................
++Pindolol (Visken, G)..................
++Propranolol (Inderal, G)..............
++Sotalol (Betapace,G)....................
++Timolol (Blocadren, G)................
+Selective (Primarily blocks beta-1 in the heart)
++Non-selective (Blocks both beta-1 in the heart and beta-2 in the periphery)
ALPHA-ADRENERGIC BLOCKERS
Doxazosin (Cardura,G).....................
Prazosin (Minipress, G).................
Tamsulosin (Flomax,G)*....................
Terazosin (Hytrin, G))......................
*only indication is BPH
CENTRAL ANTI-ADRENERGIC DRUGS
Clonidine (Catapres, G)................
(Catapress TTS;transdermal)
Guanabenz (Wytensin)...................
Guanfacine (Tenex,Intuniv,g)..........
Methyldopa (Aldomet, G)................
Table A-2
ANGINA PECTORIS MEDICATIONS [Beta-Blockers, Calcium Channel blockers see table A-1]
CATEGORY
NITRATES
Nitroglycerin
-sublingual (Nitrostat, Nitroquick, G)
-translingual (Nitrolingual)
-oral, SR (Nitro-Bid, G)
-topical ointment (Nitrol, G)
-transdermal(Transderm-Nitro,Nitro-dur,
Minitran, Deponit, G)
-transmucosal cr, Nitrogard
Isosorbide Dinitrate (Isordil, G)
Isosorbide Mononitrate (Ismo, Imdur, Monoket)
...HA, dizziness, peripheral edema
...Dizziness, nervousness, HA, GI, dry
mouth
...Same as Verapamil
...Peripheral edema, HA dizziness, flushing,
respiratory infections, cough
...Like nifedipine,less edema,dizziness
...Same as Verapamil but more edema and
tachycardia
...Peripheral edema, dizziness, HA, nausea,
gingival hyperplasia
...Hypotension, rash, HA, GI
HA, dizziness, peripheral edema -Felodipine interacts with grapefruit juice
...Hypotension, dizziness, HA, bradycardia,
gingival hyperplasia
...Less bradycardia
...Same as Propranolol
...Same as Propranolol
...Same as Atenolol
...Less bradycardia, same as Propranolol
...Dizziness, fatigue, hyperglycemia
...Orthostatic hypotension, same as
Propranolol
...Same as Propranolol
...Same as Propranolol
HA, dizziness, nausea, insomnia -Carvedilol safer with epi because of alpha
...Less bradycardia, same as Propranolol
...Less bradycardia, same as Propranolol
...Fatigue, bradycardia, GI, masks hypo-
glycemia, sudden withdrawal can lead to
rebound hypertension, xerostomia
...Same as Propranolol
+++Non-selective beta and alpha-1 blocker
* Indicated for mild to moderate CHF
...Dizziness, HA, weakness, edema
...Dizziness, Vertigo, palpitations, HA
...Dizziness, HA
...Drowsiness, dry mouth, fluid retention
...Rebound hypertension, HA, arrhythmias after
sudden withdrawal, dry mouth, sedation
...Milder than Clonidine
...Milder than Clonidine
...Sedation, orthostatic hypotension,
bradycardia, GI, oral lichenoid lesions, dry
mouth, salivary gland pain
ADVERSE EFFECTS
Dizziness, orthostatic hypotension, flushing,
HA, palpitations.
-Patients should respond to SL nitro very
rapidly and should be seated in an upright
position while awaiting effect.
-BP should be monitored and oxygen may be
supplied to the patient. Give second dose if
inadequate response after 5 min.
2
-Diltiazem and Verapamil interact with
macrolides resulting in QT interval
prolongation and possibly SUDDEN DEATH!
-Caution with position change
-Strict home care due to increased incidence
and severity of gingival overgrowth with
plaque build-up
-All CCBs may interact with Fentanyl causing
hypotension
-All CCBs may inhibit platelet function-mainly
nifedipine
-Felodipine toxicity increased by erythromycin
-pines=reflex tachycardia and peripheral
edema
-Cause problems in asthma, diabetes
-Increased pressor response to epi worst with
non-selectives and epi doses above 0.1mg or
5 carpules. Avoid interaction with selective
agent, Labetalol, or Carvedilol.
-If patient takes a non-selective, limit epi to
0.04mg (++)
-Propranolol and Metoprolol can increase
Lidocaine and BZDP levels
-Treat xerostomia
blocking effect
-Oral lichenoid lesion with Prazosin
-NSAIDs reduce effectiveness
-Caution with position change
-Oral lesions with Methyldopa
-Xerostomia worst with Clonidine but is
common for all four
-Increased pressor response to epi with
Methyldopa
-NSAIDs reduce effectiveness
-Caution with position change
TREATMENT IMPACT
-Short, midday appointments
-Premedication for stress reduction with
BZDP or nitrous oxide
-Limit epi to 0.04mg/2 hour visit
-Keep sublingual nitro or spray in office
-Do angina history often
-Max office dose of nitro is 2 tabs,do not
give third tablet if systolic BP >90mmHg
-Call 911 if chest pain not resolving after 10
minutes and 2 nitro tablets sublingually
-Halitosis with Isosorbide Dinitrate
kbaker medcomp 03/01/16
Table A-3
HEART FAILURE MEDICATIONS
CATEGORY
FIRST LINE - ACE INHIBITOR
FIRST LINE-BETA BLOCKER: carvedilol,
bisoprolol, metoprolol succinate approved
FIRST LINE DIURETIC loops preferred
SECOND LINE - ARB
SECOND LINE ALDOSTERONE ANTAGONIST:
Eplerenone or Spironolactone
THIRD LINE hydralazine or isosorbide
FOURTH LINE - digoxin
Table A-4
ANTIARRHYTHMIC MEDICATIONS
CATEGORY
Amiodarone (Cordarone, Pacerone,G)
Digoxin (Lanoxin, G)..................
Disopyramide (Norpace, G).............
Dofetilide (Tikosyn)..
Encainide (Enkaid)....................
Flecainide (Tambocor,G).................
Mexiletine (Mexitil)..................
Procainamide (Pronestyl, G)...........
Propafenone (Rythmol,G).................
Sotalol (Betapace,G)....................
Tocainide (Tonocard)..................
Table A-5
ANTIHYPERLIPIDEMIC MEDICATIONS
CATEGORY
Atorvastatin (Lipitor,G)
Ezetimibe (Zetia)...
Fenofibrate (Tricor,G)
Fluvastatin (Lescol,G)....................
Gemfibrozil (Lopid, G)..................
Lovastatin (Mevacor,G).................
Nicotinic Acid (Niacin, B3).............
Pitavastatin (Livalo)..
Pravastatin (Pravachol,G)
Rosuvastatin (Crestor)................
Simvastatin (Zocor,G).....................
Simvastatin/Ezetimibe (Vytorin)....
Table A-6
HEMOSTASIS MODIFIERS [# anti-platelet effect; @ anticoagulation effect] SEE DENTAL MANAGEMENT GUIDE
CATEGORY
Apixaban (Eliquis)@.....................................
Aspirin (G)#..........................................
Aspirin 25/Dipyridamole 200 ER (Aggrenox)#
Clopidogrel (Plavix,G)#..........................
Dabigatran Etexilate (Pradaxa)@.............
Edoxaban (Savaysa)@ Hypertension,nosebleed,major bleed 2.2%
Prasugrel (Effient)#......................................
Rivaroxaban (Xarelto)@..............................
Ticagrelor (Brilinta)#..
Warfarin (Coumadin,G)@.................
ADVERSE EFFECTS
-orthostatic hypotension, increased K+
-epinephrine dose limitation due to diagnosis
of HF and carvedilol or metoprolol
Electrolyte abnormalities
Orthostatic hypotension
Possible high potassium levels
-HA, dizziness, orthostasis, halitosis
-anoxrexia,GI,HA,bradycardia,vision changes
ADVERSE EFFECTS
...Oral Ulcers, neuralgic pain,Pulmonary tox.
...Anorexia, GI, HA, bradycardia
...Dry mouth, hypotension, GI, hypoglycemia
HA, chest pain, dizziness, arrhythmias
...Bradycardia, dizziness, HA, GI
...Bradycardia, dizziness, HA, GI, neutropenia
...GI, fatigue, dizziness, tremor, blood
dyscrasias
...Lupus-like syndrome, GI, hypotension, blood
dyscrasias
...Bradycardia, dizziness, GI, metallic taste
...QT,bradycardia,chest pain,fatigue
...GI, paresthesias, dizziness, tremor, blood
dyscrasias
ADVERSE EFFECTS
...GI, HA -Most cause taste disturbances
GI, HA, flatulence
GI, rash -Gag reflex is increased with all agents
...Upper Resp Infect,HA,GI,arthropathy
...GI, abnormal taste
...HA, GI, Abnormal taste
...Flushing, itching, GI
GI,muscle weakness,hypersensitivity myopathy. Avoid this combination.
...GI, local muscle pain
GI, muscle weaknes, abnormal taste
... HA, GI
GI, HA, Abnormal taste
ADVERSE EFFECTS
Major bleed 1.5-1.7%,easy bruising
...GI disturbances, GI bleeding, tinnitus
GI, bleeding,dizziness,tinnitus
...Dizziness, GI upset
GI bleeding, monitor with ECT or PTT
-DC Ticagrelor/Rivaroxaban 5d prior to
Major bleed 2-5%,syncope,stroke risk if d/c
Perisurgical bleeding may be prolonged
change but confirm surgery day.
...GI bleeding, monitor with INR,may use
Tranexamic 5% mouthrinse 10ml 2min prior to
surgery and every 6 hours for 48 hours to
promote fibrin clot formation
3
TREATMENT IMPACT
-watch for cough, orthostatic hypotension
-may need to limit epinephrine due to disease
state or noncardioselective BB
-may not resolve peripheral edema
-well tolerated
-well tolerated
-indicates more severe heart failure
-indicated more severe HF of arrhythmia
TREATMENT IMPACT
-Amiodarone interacts with Fentanyl
causing hypotension, bradycardia
-Amiodarone may increase lidocaine levels
-Oral ulcers with procainamide
-Xerostomia- worst with disopyramide
-Tikosyn levels increased by eryth/azoles
-Oral bleeding due to blood dyscrasias
-Taste disturbances with Propafenone
-Local anesthetics increase CNS adverse
effects of Propafenone
-Caution with position change/stress
-Digoxin levels are increased by BZDP,
Erythromycin, Tetracycline, Ibuprofen
-Erythromycin increases disopyramide
levels with resultant arrhythmias
-Mexiletine absorption decr. by narcotics
TREATMENT IMPACT
-Simvastatin,Pravastatin,Atorvastatin and
Fluvastatin interact with macrolides &
azole antifungals increasing risk of severe
-Colestipol reduces tetracycline level
TREATMENT IMPACT
-ASA, antibiotics, Metronidazole, Azole
antifungals inc. bleeding with warfarin
-Clopidogrel levels increased by NSAIDs
-Ticagrelor/Rivaroxaban toxicity increased
by 3A4 inhibitors such as macrolides
major surgery but consult MD for dental
-Warfarin patients with INR 1.5 to 3.5 times
normal can be managed without dose
-Consult MD before altering warfarin dose
-AVOID NSAIDs WITH ANTICOAGULANTS
kbaker medcomp 03/01/16
Table B-1
ANTIDEPRESSANT MEDICATIONS
CATEGORY
TRICYCLIC ANTIDEPRESSANTS (TCAs)
Amitriptyline (Elavil, G) 4+
Clomipramine (Anafranil,G) 3+
Desipramine (Norpramin, G) 1+
Doxepin (Sinequan, G) 2+
Imipramine (Tofranil, G) 2+
Nortriptyline (Pamelor, Aventyl, G)1-2+
Protriptyline (Vivactil) 3+
MISCELLANEOUS ANTIDEPRESSANTS
Nefazodone (Serzone, g) 2-3+..
Trazodone (Desyrel, g) 1+..
Vilazodone (Viibryd) 1+.
SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)
Desvenlafaxine (Pristiq) 0+
Duloxetine (Cymbalta,g) 0-1+
Levomilnacipran (Fetzima) 0-1+..
Milnacipran (Savella) 0-1+.
Venlafaxine (Effexor,g) 0-1+..........
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
Citalopram (Celexa,g) 0-1+..
Escitalopram (Lexapro,G) 0-1+.........
Fluoxetine (Prozac, G) 0-1+..........
Fluvoxamine (Luvox,g) 0-1+..........
Paroxetine (Paxil,G) 0+..........
Sertraline(Zoloft,G) 0+...........
Vortioxetine (Brintellix) 0-1+
ALPHA-2 RECEPTOR ANTAGONIST
Mirtazapine (Remeron,G) 2+
AMINOKETONE ANTIDEPRESSANTS
Bupropion (Wellbutrin, Zyban,G) 2+.
LITHIUM
Lithium Carbonate (Eskalith, Lithane,
Lithonate, G)
MONOAMINE OXIDASE INHIBITORS (MAOIs)
Isocarboxazid (Marplan) 2+
Phenelzine (Nardil,G) 2+
Selegiline Transdermal (Emsam) 1-2+
Tranylcypromine (Parnate,G) 2+
ADVERSE EFFECTS
Sedation, dry mouth, orthostatic hypotension,
tachycardia. Greater than 100mg daily of the
first five listed TCAs poses an interaction
threat with epi so limit to 2.5 carps/2h visit
Greater than 50mg daily of nortriptyline poses
epi interaction threat so limit to 2.5 carps/2h
visit
risk of liver failure limits usefulness
increases serotonin, used for insomnia
SSRI/serotonin receptor agonist for MDD
Sedation, dizziness, less BP increase
.Nausea,dry mouth,constipation,fatigue
.Indicated for major depressive disorder
.Indicated for fibromyalgia only, nausea,
fatigue,constipation,dizziness
....Dizziness, anxiety, tremor, BP increases
Nausea, dry mouth, sedation, insomnia
.reduced side effects, well tolerated
...HA, insomnia, irritability
...Insomnia,anxiety,tremor,dry mouth
...Nausea, sedation, dry mouth,dizziness
...Insomnia, dizziness, HA, tremor, dry
mouth, GI
ALL SSRIs CAUSE BRUXISM!!
Drowsiness, dizziness, weight gain
NO BRUXISM REPORTED
Seizures, agitation, insomnia, dry mouth
Tremor, GI, thirst, polyuria, edema, taste
disturbances, abnormal facial movements
Orthostatic hypotension, tachycardia, HA,
restlessness,insomnia, dizziness,
overstimulation including increased anxiety,
agitation, and manic symptoms, dry mouth,
Paresthesias, diarrhea
ASK ABOUT DIETARY RESTRICTIONS
4
TREATMENT IMPACT
-Epi interacts with high-dose TCA therapy
-Additive CNS depression with opioids
and anti-anxiety agents
-TCAs cause most severe xerostomia
-Record baseline and post-treatment BP if
vasoconstrictor is used
-Quinolone antibiotics with TCAs may
produce arrhythmias
-all increase CNS depression when
combined with opioids
-Additive CNS depressant effects with
Trazodone and opioids
-Much less dry mouth than TCAs
-Most likely to increase BP of all anti-
depressant groups-dose related
-Most likely antidepressant group to be
used for neuropathic or chronic pain
-macrolides and azole antifungals may
increase Citalopram levels
-Much less dry mouth than TCAs
-Sertraline decreases diazepam
clearance by 32%
- Fluvoxamine increases BZDP levels,best
TO AVOID COMBINATION.
-Limit tramadol dosage due to possible
serotonin syndrome
BZDPs increase psychomotor impairment
Minimal dry mouth,
Minimal SSRI-type side effects
Sedation and weight gain are problems
-lowest risk of sexual dysfunction of all
antidepressant groups
-seizure risk above 300mg/day
-Lithium levels are increased by NSAIDs
Ibuprofen, Naproxen, and Piroxicam.
Best to use Diflunisal or Sulindac
-Limit total epi dose to 0.04mg in MAOI
patients and aspirate repeatedly
-AVOID Meperidine and Fentanyl
-AVOID decongestants (Sudafed, PPA)
and amphetamines
-Record baseline and post-treatment BP
kbaker medcomp 03/01/16
Table B-2
ANTI-ANXIETY MEDICATIONS
CATEGORY
BENZODIAZEPINES (BZDPs)
Alprazolam (Xanax,G)
Chlordiazepoxide (Librium, G)
Clorazepate (Tranxene, G)
Diazepam (Valium, G)
Estazolam (ProSom)
Lorazepam (Ativan, G)
Oxazepam (Serax, G)
Temazepam (Restoril, G)
Triazolam (Halcion,G)
OTHER ANTI-ANXIETY AGENTS
Buspirone (Buspar,G)...................
Diphenhydramine (Benadryl, G)........
Eszopiclone (Lunesta,g)..
Hydroxyzine (Atarax, Vistaril, G)....
Ramelteon (Rozerem).......
Suvorexant (Belsomra).
Zaleplon (Sonata,g) Dizziness, blurred vision, fatigue
Zolpidem (Ambien,g,Intermezzo)
Table B-3
ANTIPSYCHOTIC MEDICATIONS
CATEGORY
PHENOTHIAZINES: ALIPHATIC
Chlorpromazine (Thorazine, G)
Promazine (Sparine)
PHENOTHIAZINES: PIPERIDINE
Mesoridazine (Serentil) 3+
Thioridazine (Mellaril, G) 3+
PHENOTHIAZINES: PIPERAZINE
Fluphenazine (Prolixin,Permitil,G)
Perphenazine (Trilafon, G)
Prochlorperazine (Compazine, G)
Trifluoperazine (Stelazine, G)
PHENOTHIAZINES: THIOXANTHENES
Thiothixene (Navane, G) 1+
BUTYROPHENONE
Haloperidol (Haldol, G) 1+
ATYPICAL OR SECOND GENERATION
Aripiprazole (Abilify) 0-1+
Asenapine (Saphris) 1+
Clozapine (Clozaril, G) 3+
Iloperidone (Fanapt) 0-1+
Lurasidone (Latuda) 1+
Olanzepine (Zyprexa,G) 2+
Pimozide (Orap) 2+
Quetiapine (Seroquel,G) 0-1+
Risperidone (Risperdal,G) 0-1+
Ziprasidone (Geodon,G) 1+
ADVERSE EFFECTS TREATMENT IMPACT
Drowsiness, ataxia, rebound insomnia, with- -CNS depressants are additive with BZDPs
drawal symptoms (difficult with Alprazolam), -BZDP effects increased by Erythromycin,
dizziness Ketoconazole, OCs, Cimetidine,
Propranolol, Metoprolol
...Dizziness, nausea, HA, nervousness -Xerostomia can be very pronounced
...Dry mouth, sedation, tachycardia -CNS depressants are additive
HA, unpleasant taste, drowsiness -Macrolides, azole antifungals and
...Dry mouth, sedation, tachycardia doxycycline increase Lunesta levels
...dizziness, HA, sonmolence -Atropine potentiates anticholinergic
somnolence,dizziness,C-IV effects of antihistamines
-Macrolides and azole antifungals increase
...HA, sedation, myalgia, nausea Sonata and Rozerem levels
ADVERSE EFFECTS TREATMENT IMPACT
2+ Drowsiness, dry mouth, orthostatic -CNS depressants potentiate these drugs
3+ hypotension, movement disorders that can be in all cases, meperidine is worst
both reversible and irreversible (tardive -Epi effect may be decreased due to a
dyskinesia) weak alpha-blocking effect of some
antipsychotics
-Dental management of tardive dyskinesia
takes pre-planning
-Caution with position change
-Xerostomia can be severe
Drowsiness, dry mouth, orthostatic -Same as above
hypotension, movement disorders
1+ -Same as above except little or no interaction
1+ with epi
1+
1+
Movement disorders, dry mouth, drowsiness -Llittle or no interaction with epi
Movement disorders, orthostatic hypotension, -Same as above except little or no
tardive dyskinesia interaction with epi
..HA,agitation, anxiety, insomnia, weight gain -Asenapine intx with fluoroquinolones
...sedation, EPS, loss of oral sensation -Clozapine with BZDP can produce resp.
..Drowsiness, dizziness, salivation, depression and hypotension
dry mouth, md, aplastic anemia 1.3%, -Lorazepam levels incr. by Quetiapine
dizziness,sedation,weight gain
nausea, sedation, movement disorders -Macrolides and azole antifungals intx with
..Weight gain, sedation good for refractory aripiprazole, iloperidone, lurasidone,
..Movement disorders, drowsiness,dry mouth pimozide and Quetiapine-increase
..HA, drowsiness, dizziness antipsychotic levels
..HA, insomnia,agitation, weight gain, EPS -Clozapine may reduce effects of codeine,
..HA, drowsiness, dizziness, weight gain hydrocodone, oxycodone, tramadol
5
kbaker medcomp 03/01/16
Table B-4
ANTICONVULSANT MEDICATIONS
CATEGORY
Carbamazepine (Tegretol, Carbatrol, G)......
Clonazepam (Klonopin, G)...................
Felbamate (Felbatol,G)..
Gabapentin (Neurontin,G)..................
Lamotrigine (Lamictal,G)....................
Levetiracetam (Keppra,G).
Oxcarbazepine (Trileptal)..
Phenobarbital (G).......................
Pregabalin (Lyrica,G).
Phenytoin (Dilantin, G).................
Sodium Valproate(Depakene, Depakote, G).
Tiagabine (Gabitril,G).
Topiramate (Topamax,G)
Zonisamide (Zonegran).
Table B-5
ANTIPARKINSON'S DISEASE MEDICATIONS
CATEGORY
DOPAMINERGIC AGENTS
Amantadine (Symmetrel, G)...............
Bromocriptine (Parlodel)................
Carbidopa/Levodopa (Sinemet/CR, G)......
Pergolide (Permax).....................
Pramipexole (Mirapex)
Ropinirole (Requip,G).
ANTICHOLINERGICS
Benztropine (Cogentin, G)
Biperiden (Akineton)
Trihexyphenidyl (Artane, G)
MISCELLANEOUS PARKINSON'S DISEASE AGENTS
Rasagiline (Azilect,g)
Selegiline (Eldepryl,G)..................
Entacapone (Comtan,G)
Tolcapone (Tasmar).
Table B-6
ADD/ADHD MEDICATIONS
CATEGORY
CNS STIMULANTS
Atomoxetine (Strattera)
Methylphenidate (Concerta, Metadate CR/ED,
Ritalin, Ritalin-SR, G)
Dexmethylphenidate (Focalin, G)
Dextroamphetamine (Dexedrine, G)
Lisdexamfetamine (Vyvanse)
Amphetamine mixtures (Adderall,G)
ADVERSE EFFECTS
...Drowsiness, ataxia, severe blood dyscrasias
...Drowsiness, ataxia, behavior disorders
Aplastic anemia, liver failure, HA
...Dizziness, ataxia, fatigue, nystagmus
...Dizziness, ataxia, HA, diplopia, rash
Drowsiness, dizziness
Drowsiness, ataxia
...Sedation, behavior disorders
Drowsiness, dry mouth, peripheral edema
...Drowsiness, ataxia, gingival hyperplasia
...GI, HA, ataxia, drowsiness, tremor,
thrombocytopenia
dizziness, HA, tremor, nervousness
...Drowsiness, dizziness, fatigue
Drowsiness, dizziness, nausea
ADVERSE EFFECTS
...Nausea, Dizziness, insomnia, dry mouth
...Nausea, abnormal movements, dizziness,
drowsiness
...Movement disorders, GI, altered taste,
excessive salivation, bruxism
...Nausea, abnormal movements, sedation,
rhinitis
hallucinations,nausea, dizziness, sedation,
sudden sleep attacks
syncope, nausea, dissiness, sedation
Drowsiness, dry mouth, tachycardia, confusion
arthralgias, depression, dyspepsia, falls
...Nausea, dizziness, confusion, dry mouth
diarrhea, avoid sudden d/c
diarrhea, avoid sudden d/c
ADVERSE EFFECTS
GI,anorexia, dizziness, mood swings, no abuse
May cause seizures, nervousness, insomnia,
dizziness, HA, dyskinesia, tachycardia,
anorexia
Dex- dry mouth, dysgeusia, no seizure increase
Prodrug of dextroamphetamine-less abuse
potential but still Schedule II CS
Amphet-dry mouth dyskinetic movements,
increased BP, pulse
6
TREATMENT IMPACT
-CNS depressants will potentiate all
drugs in this category
-Possible bleeding with Valproate
-Gingival overgrowth with Phenytoin
-Erythromycin and propoxyphene increase
Carbamazepine levels
-Erythromycin increases Depakene levels
-Low stress environment-consider
sedative premedication (BZDP)
-Take seizure control history often
-Aspirin increases Depakene levels
-Carbamazepine increases APAP liver
toxicity, decreases APAP effect
-Phenytoin may increase meperidine
toxicity and decrease its effectiveness
TREATMENT IMPACT
-Levodopa can increase effects of epi
-Patient management is difficult due to
movements and excess saliva
-Macrolides increase Ropinirole
-Xerostomia can be severe
-CNS depressants have additive effect
-Confusion is common
-rasagiline is a MAOI (type B) inhibitor so
avoid antidepressants, cyclobenzaprine,
dextromethorphan, fluoroquinolones,
meperidine, pseudoephedrine, and some
sympathomimetic amines. Limit epi dose to
0.04mg per 2 hour dental visit.
-Selegiline is a MAOI (type B) so avoid
Meperidine, limit total epi dose to 0.04mg
until this interaction is investigated
-Limit epi with Comtan or Tasmar
-Erythromycin may increase Comtan levels
TREATMENT IMPACT
1. Meth, Amphet and Dex interact with
MAOIs and furazolidine
2. Dex and Amphet interact with TCAs-
decreased dex or amphet effects
3. Low stress environment
4. Monitor BP and pulse
5. Possible caries increased
6. Fluoxetine and Paroxetine will increase
levels of atomoxetine (Strattera)
kbaker medcomp 03/01/16
Table C-1
SEX HORMONES

CATEGORY ADVERSE EFFECTS TREATMENT IMPACT

ORAL CONTRACEPTIVES (Combination or Triphasic are Most Commonly Prescribed)

(Lo-Ovral, Ortho Novum, Brevicon, Modicon,
Norinyl, Genora, Tri-levlen, etc.)
Seasonale is a combination OC with only four
menstrual periods per year
Nausea, HA, edema, weight gain, intraoral
soft tissue changes (gingivitis)
[if dental antibiotics are taken for 48 hours or
more, advise additional barrer contraception
for the remainder of the pill pak.]
-Progestin causes increased inflammatory
response to plaque
-Increased dry socket for 21/28 days
-BZDP will have longer activity with OCs
-Oral mucosa is more resistant to trauma

HORMONE REPLACEMENT THERAPY (HRT)

Conjugated Estrogens, equine (Premarin, G) Edema, HA, melasma, nausea, increased risk -Oral mucosa is more resistant to
Conjugated Estrogens, synthetic (Cenestin) of thromboembolic episode ulcerationBone density is increased
Esterified Estrogens (Estratab, Menest)
Estradiol (Estrace) transdermal (Alora, Climara, -BLACK BOX WARNING FOR POSSIBLE
Estraderm, Fem Patch, Vivelle-Dot) INCREASED RISK OF CARDIAC AND
THROMBOEMBOLIC EVENTS

Table C-2
ORAL ANTIDIABETIC MEDICATIONS SEE DENTAL MANAGEMENT GUIDE

CATEGORY ADVERSE EFFECTS TREATMENT IMPACT

BIGUANIDES
Metformin (Glucophage, G) .
Metformin/glipizide (Metaglip)
Metformin/glyburide (Glucovance) ..
Metformin/pioglitazone (Actoplus Met) .
Metformin/rosiglitazone (Avandamet)
SECOND GENERATION SULFONYLUREAS (GL for Glucose Reduction)
Glimepride (Amaryl, g)
Glipizide (Glucotrol,XL,G)
Glyburide Micronase,Glynase PresTab, G)
-Diarrhea,bloating, Vit B-12 malabsorp, taste
-Hypoglycemia, GI
-Hypoglycemia, GI
-GI, URI, HA, sinusitis, bloating, taste
-GI, URI, HA, edema, bloating, taste disturb.
-Hypoglycemia, HA
Hypoglycemia, GI, weight gain
- Metformin with prednisone may cause lactic
acidosis
-possible hypoglycemia with Metaglip and
Glucovance combination drugs
-Metformin is first line therapy
-No risk of hypoglycemia as a single agent
-NSAIDs and high-dose Salicylates (aspirin)
increase hypoglycemia with all agents
-Precautions about preventing hypoglycemia
-Altered host resistance in poor control

ALPHA-GLUCOSIDASE INHIBITORS
Acarbose (Precose) GI, flatulence, diarrhea -no hypoglycemia as single agents
Miglitol (Glyset) Flatulence, diarrhea
THIAZOLIDINEDIONES ("GLITAZONES")
Pioglitazone (Actos,G) URI, HA, sinusitis -macrolides and azole antifungals inc. levels
Rosiglitazone (Avandia) URI, HA, edema -no hypoglycemia as single agent

DPP-4 INHIBITORS (GLIPTINS)

Incretin Enhancers
Alogliptin (Nesina) -nasopharyngitis,HA,URI -acute pancreatitis and hepatic toxicity have
Linagliptin (Tradjenta). -hypoglycemia, nasopharyngitis, GI been seen with all DPP-4 inhibitors
Saxagliptin (Onglyza) -hypoglycemia, HA, peripheral edema
Sitagliptin (Januvia) .. -hypoglycemia, GI -DPP-4 inhibitors may cause hypersensitivity
reactions including rash and angioedema

GLP-1 AGONISTS (GLUTIDES)
Albiglutide (Tanzeum)......................................
Dulaglutide (Trulicity).......................................
Exenatide (Byetta) ............................................
Liraglutide (Victoza).........................................
SGLT2 INHIBITORS (FLOZINS)
Canagliflozin (Invokana)......................................
Dapagliflozin (Farxiga)........................................
Empagliflozin (Jardiance)...................................
Incretin Mimetics
-lower incidence of nausea than others
-low risk of hypoglycemia
-acute pancreatitis, nausea, hypoglycemia
-possible thyroid C-cell tumor risk, GI,HA,
hypoglycemia
-may increase risk of stroke
-may increase risk of bladder cancer
-Use all with caution in with renal disease
These agents are all injectable only
-All reduce APAP levels so give APAP 1 hour
prior to injection; Also, Give oral antibiotics 1
hour prior to either injection
-All agents have low risk of hypoglycemia
-All agents cause weight loss
-All agents are very expensive
-All cause weigh loss and decreased BP
-Low risk of hypoglycemia
-Newest agents so role not known

7
kbaker medcomp 03/01/16
Table C-3
INSULINS
CATEGORY
RAPID AND SHORT-ACTING
Humalog,Novolog,Apidra rapid acting
Humulin R,Novolin R short acting regular
INTERMEDIATE ACTING
Humulin N, Novolin N (i.e. NPH)
LONG-ACTING
Lantus (insulin glargine)
Levemir (insulin detemir)
Table C-4
CORTICOSTEROID MEDICATIONS
CATEGORY
SHORT-ACTING
Hydrocortisone (Cortef, G)
INTERMEDIATE-ACTING
Prednisone (Deltasone, G)
Prednisolone (Delta-Cortef, G)
Triamcinolone (Kenalog, G)
Methylprednisolone (Medrol, G)
LONG-ACTING
Dexamethasone (Decadron, G)
Betamethasone (Celestone, G)
Table C-5
OSTEOPOROSIS MEDICATIONS
CATEGORY
Calcitonin-salmon nasal spray (Miacalcin)
BISPHOSPHONATES (oral and/or injectable)
-Alendronate (Fosamax oral,G-daily,weekly)
-Ibandronate (Boniva ,G-also by injection q
3mo but injection is not generic yet)
-Pamidronate (Aredia) injection only
-Risedronate (Actonel oral -daily, weekly)
-Zoledronic Acid (Zometa, Reclast)-injection
only-once yearly for osteoporosis is Reclast
-Denosumab (Prolia Injection)
Raloxifene (Evista) selective estrogen receptor
modulator which decreases breast Cancer risk
Teriparatide (Forteo) biosynthetic human
parathyroid hormone by SC injection only
ADVERSE EFFECTS
-onset 15-30 minutes, duration 3-5 hours
-onset 30-60minutes, duration 6-10 hours
-onset 1-2 hours
-duration is up to 24 hours
-onset 1.1 hours, duration 24 hours
-onset 1.1-2 hours, duration 24 hours
ADVERSE EFFECTS
Fluid retention (can be significant), insomnia,
weight gain, adrenal suppression, increased
risk of infection, poor wound healing,
hypertension, K+ loss, osteoporosis, peptic
ulcer formation, growth suppression in
children, increased friability of oral soft tissue
Diabetes may be unmasked and predominant
patient mood will be intensified. Insomnia,
nervousness, tachycardia and tremor can be
seen with moderate to high daily doses.
Same as above, but fluid retention only with
high doses of these synthetic agents
Same as above, but fluid retention only with
high doses of these synthetic agents
ADVERSE EFFECTS
Rhinitis, nausea, salty taste, dry mouth
Pain, GI, HA,possibility of osteonecrosis
of the jaw (ONJ), Zometa and Aredia are
injectable bisphosphonates for cancer
chemo hypercalcemia with much higher
risk of ONJ than oral agents. Reclast is a
once yearly dose of zoledronic acid and
is also associated with increased risk of
ONJ post alveolar bone trauma.
..Likely to have same risk of ONJ! ..Indicates intolerance to bisphosphonates
..Hot flashes, leg cramps
..Orthostatic hypotension, dizziness
8
TREATMENT IMPACT
-peak effect 30min to 1 hour
-peak effect 1-4 hours
-peak effect 6-14 hours
-peak effect 4-12 hours
-NO SIGNIFICANT PEAK
-NO SIGNIFICANT PEAK
TREATMENT IMPACT
-"Window of vulnerability" is
hydrocortisone 20mg-60mg daily or
prednisone 5-15mg/day for greater than
21 continuous days.
Additional steroids may be needed to
supplement the adrenal suppressed
patient during acute periods of stress
-Take extra precautions against viral or
bacterial infection
-Watch for signs or symptoms of oral
yeast infections
-Avoid Salicylates such as aspirin
-Same as above
-Erythromycin inhibits metabolism of
Methylprednisolone
-dexamethasone induces CYP2D6 so
enhances codeine and hydrocodone-
acute perioperative use in oral surgery
doesnt increase post-op complications
TREATMENT IMPACT
-local irritation or oropharynx is possible
Must be taken with 8oz. of water first thing in the
AM. No other medications within 30 minutes of
all dronates. ONJ- Minimize trauma, possibly
avoid implants, early recognition of painful
extraction site lesions, AVOID DEBRIDEMENT!!!
-Print patient information sheet from the ADA
website For the Dental Patient under the title
Bisphosphonate Medications
Increased raloxifene with NSAIDs and BZDPs
Increased risk of osteosarcoma in rats using 3-
20x human dosages, increased serum calcium
levels possible
kbaker medcomp 03/01/16
Table D
RESPIRATORY SYSTEM MEDICATIONS

CATEGORY ADVERSE EFFECTS TREATMENT IMPACT

ANTIHISTAMINES
Azatadine (Optimine, Trinalin)
Drowsiness, dry mouth, palpitations, -Dry mouth can be significant with
Azelastine (inhaled) (Astelin,G)
thickening of bronchial secretions with diphenhydramine and hydroxyzine
Brompheniramine (Dimetane, G)
traditional antihistamines such as
Carbinoxamine (Clistin)
chlorpheniramine,diphenhydramine,
Cetirizine (Zyrtec, OTC, G) -CNS depressants have additive effects
hydroxyzine and triprolidine
Chlorpheniramine (Chlor-Trimeton, G) with diphenhydramine and hydroxyzine
Clemastine (Tavist, G) (Cetirizine, Fexofenadine and Loratidine have
Cyproheptadine (Periactin, G) limited anticholinergic side effects.) -Oral lesions with Triprolidine
Desloratidine (Clarinex,G)
Diphenhydramine (Benadryl, G)
Fexofenadine (Allegra, Allegra OTC,G)
Hydroxyzine (Atarax, Vistaril, G)
Loratidine (Claritin, G, OTC)
Triprolidine (Actifed, G)

SYMPATHOMIMETIC BRONCHODILATORS

INHALERS
Albuterol (Proventil, Ventolin, G) Tremor, tachycardia, bad taste, oral irritation -Inhaler use just prior to dental treatment
Arformoterol (Brovana) - LA may prevent asthma during the
Bitolterol (Tornalate) -long acting (LA) beta agonist for COPD and appointment. (Don't use LA beta agonist
Formoterol (Foradil) - LA can exacerbate acute bronchospasm during an inhaler or corticosteroid inhaler.)
Indacaterol (Arcapta Neohaler - LA asthma attack
Levalbuterol (Xopenex) -Dental office should have Albuterol
Metaproterenol (Metaprel, Alupent, G) inhaler available for patients
Pirbuterol (Maxair)
Salmeterol (Serevent,Advair Diskus) - LA Headache due to its long action
Terbutaline (Brethaire)

SYSTEMIC TABLETS -Dry mouth can be significant

Albuterol (Proventil, Ventolin, G) Tremor,tachycardia, insomnia, irritability, dry
Metaproterenol (Metaprel, Alupent) mouth
Terbutaline (Brethine)

XANTHINE BRONCHODILATORS
Theophylline Bead-filled caps (Slo-Bid, Slo-
Nausea, HA, tachycardia, insomnia, tremor, -Used mostly as chronic medication
Phylline, etc.)
irritability because caffeine derivative -Ketoconazole decreases Theophylline l
Theophylline SR tablets (Theolair-SR,
-Erythromycin increases Theophylline
Constant-T, G, etc.)

CORTICOSTEROID RESPIRATORY AGENTS

INHALERS
Beclomethasone (Vanceril, Vancenase/AQ DS, Soft palate irritation, atrophic candida on the -Check often for palatal candida infection
Beclovent, Beconase/AQ) soft palate or buccal mucosa -Recommend an inhaler adapter to
Budesonide (Rhinocort, Pulmicort,g) prevent atrophic candida
Flunisolide (AeroBid, Nasalide, Naserel) -Rinse with water after each use.
Fluticasone (Flonase, Flovent,Advair Diskus)
Triamcinolone (Azmacort, Nasacort/AQ)

SYSTEMIC TABLETS
(see Corticosteroid Table C-4)

MISCELLANEOUS RESPIRATORY AGENTS

Cromolyn (Intal, Nasalcrom, Gastrocom)........... ...Throat irritation, cough -All are for chronic therapy only
Ipratropium (Atrovent,G)............... ...HA, dry oropharynx -Ipratropium is used for COPD
Ipratropium/Albuterol (Combivent). Tremor, throat irritation -Ipratropium now for short-term rhinitis
Nedocromil (Tilade).................... ...Bad taste, cough in 5yo and up

LEUKOTRIENE RECEPTOR ANTAGONISTS

Montelukast (Singulair,G) -HA, pharyngitis, cough -Phenobarb dec. montelukast levels
Zafirlukast (Accolate) -HA, lethargy, rare vasculitis -Zafirlukast levels dec. by 40% with
Zileuton (Zyflo) -rare hepatic toxicity erythromycin
-Zafirlukast levels inc. by 45% with
Aspirin

9
kbaker medcomp 03/01/16
Table E
GASTROINTESTINAL MEDICATIONS

CATEGORY ADVERSE EFFECTS TREATMENT IMPACT

ANTICHOLINERGICS/ANTISPASMODICS

Clidinium Br (Quarzan)
Dicyclomine (Bentyl, G)
Glycopyrrolate (Robinul)
Oxybutynin (Ditropan)
Propantheline Br (Pro-Banthine, G)
H2 ANTAGONISTS
Cimetidine (Tagamet,HB=OTC,G)
Famotidine (Mylanta AR, Pepcid,AC=OTC)
Nizatidine (Axid,AC=OTC)
Ranitidine (Zantac,EFFER,GEL,
75mg and 150mg =OTC)
Dry mouth, altered taste, dysphagia,
palpitations, drowsiness, excitement
HA, fatigue, thrombocytopenia, rarely erythema
multiforme
-Dry mouth can be very significant
-CNS drugs can have additive effects
-Some are used to decrease saliva flow
during dental visits
-Cimetidine decreases clearance of
BZDPs, Lidocaine, Carbamazepine,
Metronidazole
-All H2 agents decrease absorption of
Ketoconazole, but not Fluconazole

PROSTAGLANDIN E-2 ANALOGUE

MISOPROSTOL (Cytotec)
PROTON PUMP INHIBITORS
Dexlansoprazole (Dexilant).
Esomeprazole (Nexium)..
Lansoprazole (Prevacid,G)
Omeprazole (Prilosec, G, OTC)
Pantoprazole (Protonix).
Rabeprazole (Aciphex).
GASTROINTESTINAL PROKINETIC AGENTS
Metoclopramide (Reglan,G)........
Abortifacient, diarrhea
Diarrhea, abdominal pain, nausea
HA, GI including diarrhea
HA, GI including diarrhea
HA, GI, myalgias
HA, GI, hyperglycemia
HA, dizziness, infection
..Fatigue,drowsiness,movement disorders
..HA, diarrhea, abdominal pain
-Patient at high risk for GI ulcers so
avoid aspirin and NSAIDs
-BZDP levels increased,fluconazole
increases dexlansoprazole levels
-Clarithromycin increases omeprazole
-Omeprazole & rabeprazole increase
half-life of diazepam and triazolam
-All decrease Ca, Mg, B12 absorption
-Narcotics antagonize metoclopramide
-CNS depressants can add to
drowsiness with Metoclopramide

Table F
IMMUNOMODULATORS AND BIOLOGICS

CATEGORY ADVERSE EFFECTS TREATMENT IMPACT

HYDROXYCHLOROQUINE Eye toxicity, oral lichenoid lesions, Oral melanosis or ulcerative lesions

(Plaquenil, G) pigmentation or oral mucosa

SULFASALAZINE (Azulfidine, G) GI, HA, fever, blood dyscrasias -Antibiotics may interfere with effects

TISSUE NECROSIS FACTOR INHIBITORS AND BIOLOGICS

Adalimumab (Humira) TNF ..URI, UTI, oral thrush, ulcerative stomatitis -All drugs in this category cause oral
ulcerations and increased infections
Anakinra (Kineret) IL-1 inhibitor.. ..injection site rx, URI, HA, nausea
Apremilast (Otezla) PDE-4 Inhibitor
..Depression,diarrhea, nausea, HA -Compromised host defense
Azathioprine( Azasan,Imuran,g).......... mechanisms indicate need to minimize
..Neutropenia, URI, UTI, Oral Thrush infection risk

Certilizumab (Cimzia) TNF..
Cyclophosphamide (Cytoxan,g).............
Cyclosporine (Sandimmune, Neoral,g)......
Etanercept (Enbrel) TNF .
Golimumab (Simponi ) TNF.
...Nausea, vomiting, bone marrow suppression -Cyclosporine gingival overgrowth is
URI,UTI, arthralgia,rash,increased CA risk? dose related and occurs in 5-16%
-Cyclosporine levels increased with
Erythro, Ketoconazole, Fluconazole
...Alopecia, bone marrow suppression, sterility
-NSAIDs increase renal toxicity of Cyc
...Renal dysfunction, hypertension, hirsutism,
tremor, gingival overgrowth
URI, HA, other infections, increase CA risk?

Infliximab (Remicade) TNF..... URI,Herpes, blood dyscrasias

Leflunomide (Arava) URI, UTI, Oral Thrush, increased cancers -NSAID levels increased by Arava

10
kbaker medcomp 03/01/16
 diarrhea, alopecia, URI
Methotrexate (Rheumatrex, G)...........
...GI ulceration, bone marrow suppression
Rituximab (Rituxan ) B cell depleter
URI, nasopharyngitis, bronchitis
-30% rate or oral ulcers with
methotrexate chronic therapy
-NSAIDs increase Methotrexate levels

Tacrolimus (Prograf,G). CNS Stimulation, Renal Dysfunction, blood -Macrolides and azole antifungals may
dyscrasias, metabolic disorders increase tacrolimus levels
URI,nasopharyngitis,HA,hypertension
Tocilizumab (Actemra ) IL-6 inhibitor

Table G
CANCER CHEMOTHERAPY AGENTS KNOWN TO CAUSE SIGNIFICANT ORAL MUCOSITIS

Additional Readings

The National Institute of Dental and Craniofacial Research has many resources concerning this topic. Their website has a section
devoted to Cancer Treatment and Oral Health. They cover the following topics:

For health professionals

o Dental Provider's Oncology Pocket Guide
o Oncology Pocket Guide to Oral Health
o Oral Complications of Cancer Treatment: What the Dental Team Can Do

For patients
o Chemotherapy and Your Mouth
o Head and Neck Radiation Treatment and Your Mouth
o Three Good Reasons to See a Dentist BEFORE Cancer Treatment
The above information, and more, can be found at: http://www.nidcr.nih.gov/OralHealth/Topics/CancerTreatment/

Acton QA. Xerostomia: New insights for the healthcare professional. Scholarly Editions (2013).

Deboni AL, Giordani AJ, Lopes NN, Dias RS, et al. Long-term oral effects in patients treated with radiochemotherapy for
head and neck cancer. Support Care Cancer. 2012 Nov;20(11):2903-2911.

Gilliam K. Oral health maintenance in head and neck cancer patients. RDH April (2014), 63-76.

Haas M, McBride DL. Managing the oral effects of cancer treatment: Diagnosis to survivorship. Pittsburgh: Oncology
Nursing Society (2011).

Meurman JH, Gronroos L. Oral and dental healthcare of oral cancer patients: Hyposalivation, caries and infections. Oral
Oncology, (2010) 46, 464-467.

Xerostomia: Helping patients with dry mouth. (2014, January 1).

11
kbaker medcomp 03/01/16
 JNC 8 Hypertension Guideline Algorithm
Initial Drugs of Choice for Hypertension
Adult aged 18 years with HTN ACE inhibitor (ACEI)
Implement lifestyle modifications
Angiotensin receptor blocker (ARB)
Set BP goal, initiate BP-lowering medication based on algorithm
Thiazide diuretic
General Population Calcium channel blocker (CCB)
(no diabetes or CKD) Diabetes or CKD present
Strategy Description
Age 60 years Age < 60 years All Ages All Ages and Races Start one drug, titrate to maximum
Diabetes present CKD present with or
A
dose, and then add a second drug.
No CKD without diabetes
BP Goal BP Goal B Start one drug, then add a second
< 150/90 < 140/90 drug before achieving max dose of
BP Goal BP Goal first
< 140/90 < 140/90
C Begin 2 drugs at same time, as
separate pills or combination pill.
Initiate ACEI or ARB, Initial combination therapy is
Nonblack Black
alone or combo recommended if BP is greater than
w/another class 20/10mm Hg above goal
Initiate thiazide, ACEI, ARB, Initiate thiazide or CCB,
or CCB, alone or in combo alone or combo
Lifestyle changes:
Yes Smoking Cessation
At blood pressure goal?
Control blood glucose and lipids
No
Diet
Reinforce lifestyle and adherence Eat healthy (i.e., DASH diet)
Titrate medications to maximum doses or consider adding another medication (ACEI, ARB, CCB, Thiazide) Moderate alcohol consumption
Reduce sodium intake to no
Yes more than 2,400 mg/day
At blood pressure goal?
Physical activity
No
Moderate-to-vigorous activity
Reinforce lifestyle and adherence 3-4 days a week averaging 40
Add a medication class not already selected (i.e. beta blocker, aldosterone antagonist, others) and titrate min per session.
above medications to max (see back of card)
Yes
At blood pressure goal? Continue tx and monitoring
No
Reference: James PA, Ortiz E, et al. 2014 evidence-based guideline for the management
Reinforce lifestyle and adherence of high blood pressure in adults: (JNC8). JAMA. 2014 Feb 5;311(5):507-20
Titrate meds to maximum doses, add another med and/or refer to hypertension specialist
Card developed by Cole Glenn, Pharm.D. & James L Taylor, Pharm.D.
 Compelling Indications
Hypertension Treatment
Indication Treatment Choice
Heart Failure ACEI/ARB + BB + diuretic + spironolactone
Post MI/Clinical CAD ACEI/ARB AND BB
Beta-1 Selective Beta-blockers possibly safer in patients
CAD ACEI, BB, diuretic, CCB with COPD, asthma, diabetes, and peripheral vascular
Diabetes ACEI/ARB, CCB, diuretic disease:
metoprolol
CKD ACEI/ARB bisoprolol
Recurrent stroke prevention ACEI, diuretic betaxolol
acebutolol
Pregnancy labetolol (first line), nifedipine, methyldopa
Drug Class Agents of Choice Comments
Diuretics HCTZ 12.5-50mg, chlorthalidone 12.5-25mg, indapamide 1.25-2.5mg Monitor for hypokalemia
triamterene 100mg Most SE are metabolic in nature
K+ sparing spironolactone 25-50mg, amiloride 5-10mg, triamterene Most effective when combined w/ ACEI
100mg Stronger clinical evidence w/chlorthalidone
Spironolactone - gynecomastia and hyperkalemia
furosemide 20-80mg twice daily, torsemide 10-40mg Loop diuretics may be needed when GFR <40mL/min
ACEI/ARB ACEI: lisinopril, benazapril, fosinopril and quinapril 10-40mg, ramipril 5- SE: Cough (ACEI only), angioedema (more with ACEI),
10mg, trandolapril 2-8mg hyperkalemia
ARB: candesartan 8-32mg, valsartan 80-320mg, losartan 50-100mg, Losartan lowers uric acid levels; candesartan may
olmesartan 20-40mg, telmisartan 20-80mg prevent migraine headaches
Beta-Blockers metoprolol succinate 50-100mg and tartrate 50-100mg twice daily, Not first line agents reserve for post-MI/CHF
nebivolol 5-10mg, propranolol 40-120mg twice daily, carvedilol 6.25-25mg Cause fatigue and decreased heart rate
twice daily, bisoprolol 5-10mg, labetalol 100-300mg twice daily, Adversely affect glucose; mask hypoglycemic awareness
Calcium channel Dihydropyridines: amlodipine 5-10mg, nifedipine ER 30-90mg, Cause edema; dihydropyridines may be safely combined
blockers Non-dihydropyridines: diltiazem ER 180-360 mg, verapamil 80-120mg 3 w/ B-blocker
times daily or ER 240-480mg Non-dihydropyridines reduce heart rate and proteinuria
Vasodilators hydralazine 25-100mg twice daily, minoxidil 5-10mg Hydralazine and minoxidil may cause reflex tachycardia
and fluid retention usually require diuretic + B-blocker
terazosin 1-5mg, doxazosin 1-4mg given at bedtime Alpha-blockers may cause orthostatic hypotension
Centrally-acting clonidine 0.1-0.2mg twice daily, methyldopa 250-500mg twice daily Clonidine available in weekly patch formulation for
Agents resistant hypertension
guanfacine 1-3mg
 DENTAL MANAGEMENT GUIDE FOR HYPERTENSION

DENTAL MANAGEMENT GUIDE FOR ANTICOAGULANTS

 DENTAL MANAGEMENT OF THE DIABETIC PATIENT

Type 1 or insulin treated type 2 diabetes

Short procedures Generally, patients who use insulin can continue with subcutaneous insulin perioperatively
(rather than an insulin infusion) for procedures that are not long and complex (eg, less than two hours. For minor,
early morning procedures where breakfast is likely only delayed, patients may delay taking their usual morning (short-
or rapid-acting insulin) insulin until after the surgery and before eating. However, patients who take once-daily long-
acting insulin (eg, glargine) or who use continuous insulin infusion (insulin pump) may continue basal insulin without
any change to their usual regimen, as long as the basal insulin dose has been correctly calculated. In patients whose
basal rate is calculated to keep the blood glucose in normal or low-normal ranges or when there is history of low
glucose measures as an outpatient, we often reduce the dose (or rate) by 10 to 20 percent to avoid any chance of
preoperative hypoglycemia. If patients need to eat to treat hypoglycemia, surgery may be cancelled. For patients
undergoing morning procedures where breakfast and possibly lunch are likely to be missed or for surgeries that take
place later in the day:

Omit any short- or rapid-acting insulin on the morning of surgery.

For patients who take two types of insulin (intermediate- or long- and rapid- or short-acting) only in the morning, give
between one-half to two-thirds of their usual total morning insulin dose (both types of insulin) as intermediate- or long-
acting insulin to provide basal insulin during the procedure.
For patients who take insulin (intermediate- or long- and rapid- or short-acting) two or more times per day, give
between one-third to one-half of the total morning dose (both types of insulin) as intermediate- or long-acting insulin.
Patients on continuous insulin infusion (insulin pump) may continue with their usual basal infusion rate, assuming that
the catheter and pump can remain safely in place during the procedure.
Start dextrose containing IV solution (D5 with either water or with one-half isotonic saline) at a rate of 75 to 125
cc/hour to provide 3.75 to 6.25 g glucose/hour to avoid the metabolic changes of starvation
Check blood sugars either by fingerstick every hour, and more frequently if blood glucose is <100 mg/dL (5.5 mmol/L)
or if the rate of fall is rapid. Fingerstick glucose levels are less reliable in patients who are critically ill, are on
vasopressor agents, or hypotensive, and venous or arterial blood and laboratory testing should be used in these cases.
For patients who develop hyperglycemia, supplemental short- or rapid-acting insulin (table 1) may be administered
subcutaneously, based on frequently measured glucose levels which are often obtained on capillary "fingerstick"
samples.
 ORAL IMPACT OF DRUG THERAPY
Karen A. Baker, M.S.Pharm.
Associate Professor
University of Iowa Colleges of Dentistry & Pharmacy

I. EFFECTS OF DRUGS ON THE SALIVARY GLANDS

A. AUTONOMIC INNERVATION OF SALIVARY GLANDS

BLOOD VESSELS: SALIVARY GLANDS:
Sympathetic alpha = constriction Sympathetic alpha & beta = viscous secretions, amylase secretion
Parasympathetic response = dilation Parasympathetic response = profuse, watery secretions

B. PTYALISM / SIALORRHEA

alprazolam (Xanax) clonidine (Catapres) levodopa (Sinemet) clozapine (Clozaril)

pilocarpine (Isopto-Carpine) lithium (Eskalith) pentoxifylline (Trental) haloperidol (Haldol)
lorazepam (Ativan) reserpine (Serpasil) valproic acid (Depakene) risperidone (Risperdal)
tacrine (Cognex) bethanechol (Urecholine) donepezil (Aricept) galantamine (Reminyl)

C. XEROSTOMIA

i) Mechanism of xerostomic drug action:

1) Interference with transmission at the parasympathetic neuro-effector junction
2) Interference with transmission at autonomic ganglia
3) Actions at the adrenergic neuro-effector junction
4) Depression of central connections of autonomic nervous system = CNS depressants

ii) Clinical symptoms of xerostomia:

- generalized burning sensation in the mouth - difficulty swallowing or speaking due to dry tissues
- sore, burning tongue - swelling of the face
- generalized oral soreness -disturbed sleep patterns
- repeated oral abrasions & ulcerations
(especially associated with denture wearing)

iii) Clinical signs of xerostomia:

generalized mucosal inflammation - infection by Candida albicans & angular cheilitis

- mucosal atrophy - retrograde infection of the salivary glands
- fissuring of the tongue - increased rate of dental caries ( especially root caries)
- predisposition to ulceration - increased plaque formation & accumulation

iv) Effects on quality of life:

- increased incidence of oral candidosis - reduced denture wearing time

- increased caries and periodontal disease - burning mouth, sore tongue, discomfort
- decreased nutritional intake - decreased compliance with medications
D. DRUGS WHICH FREQUENTLY CAUSE XEROSTOMIA:
ANTICHOLINERGICS & ANTIPARKINSONIAN AGENTS
methantheline bromide (Banthine) dicyclomine (Bentyl) trihexyphenidyl (Artane)
benztropine mesylate (Cogentin) tolterodine (Detrol) oxybutynin (Ditropan)

ANTIDEPRESSANTS
amitriptyline (Elavil) SSRIs & others buproprion (Wellbutrin)
trazodone (Desyrel) MAOIs ALL TCAs

SYSTEMIC ANTIHISTAMINES
diphenhydramine (Benadryl) clemastine (Tavist) hydroxyzine (Atarax)
chlorpheniramine (Chlor-Trimeton) triprolidine (Actifed) cetirizine (Zyrtec-OTC)

ANTIPSYCHOTICS
chlorpromazine (Thorazine) thioridazine (Mellaril) prochlorperazine (Compazine)
haloperidol (Haldol) thiothixene (Navane) trifluoperazine (Stelazine)

ANTIHYPERTENSIVES
ACE INHIBITORS BETA BLOCKERS ALPHA BLOCKERS
ARBs guanethidine (Ismelin) reserpine (Serpasil)

CNS STIMULANTS amphetamines phentermine (Fastin)

diethylproprion (Tenuate) methylphenidate (Ritalin, Concerta) pseudoephedrine (Sudafed)

DIURETICS
chlorthalidone (Hygroton) ALL THIAZIDES ALL LOOP DIURETICS
K+ SPARING AGENTS furosemide (Lasix) bumetanide (Bumex)

MISCELLANEOUS AGENTS systemic bronchodilators OPIOID ANALGESICS

muscle relaxants anticholinergics hypotensive agents

E. OTHER CONDITIONS ASSOCIATED WITH XEROSTOMIA

AIDS/HIV
Bone Marrow Transplantation
Chronic Active Hepatitis
Radiation Therapy
Primary Biliary Cirrhosis
Vasculitis
Graft vs. Host Disease
Renal Dialysis
Anxiety or Depression
Diabetes Mellitus

II. MANAGEMENT OF THE XEROSTOMIC PATIENT

A. PATIENT COUNSELING see last page of this handout (page 8)
Many patients may be successfully managed via lifestyle/habit changes alone
- the last page contains a patient information handout that can be duplicated for patients
- all xerostomic patients will benefit from those simple and inexpensive suggestions:
 B. SELECTED XEROSTOMIA RELIEF PRODUCTS (* denotes ADA acceptance)
all are OTC products and individual patient acceptance varies widely
PRODUCT (MFR) INGREDIENTS DISPENSED/SOLD PT. COST
GC America Dry Mouth Gel Polyglycerol 60%, Water 36%, NaCMC 2.5%, five Dental Office Dispensed Only $1.50/tube
(GC America (800) 323-7063 flavors-lemon,mint,orange,raspberry,fruit salad 40g tubes, order in boxes of 10 tubes dentist.net
Mouthkote xylitol, sorbitol***, yerba santa, citric acid, ascorbic 8 oz pump spray $9.50
(Parnell) acid, sodium benzoate, saccharin
Oasis Mouthwash and Mouth Spray Water, glycerin, sorbitol***, poloxamer 338, castor oil, 16oz bottle mouthwash $5.99
(GlaxoSmithKline-Consumer Healthcare) cellulose gum cetylpyridinium chloride (CPC) 1oz spray bottle $4.99
Oral Balance Moisturizing Gel or Liquid glucose oxidase enzyme system, xylitol, hydroxyethyl 42g (1.5 oz) tube of gel $8.45
(Laclede) cellulose, aloe vera, K thiocynate 45ml (1.5oz) squeeze bottle $8.45
Salivart Synthetic Saliva* NaCMC, sorbitol***, NaCl, dibasic potassium 75 gram can with Nitrogen propellant $9.50
(Gebauer Co.) phosphate,
Kcl, CaCl2 , MgCl2
Stoppers4 Dry Mouth Spray (Woodridge) Water, glycerin, xylitol,hydroxyethylcellulose,lysozyme, 1oz spray bottle $6.09
lactoferrin,glucose oxidase
V= viscosity agent = thickener P= preservative M= miscellaneous agents - buffers, flavoring
***Sorbitol - non-cariogenic sugar alcohol - chronic use in presence of decreased salivary flow may increase Strep mutans

Oralbalance (Laclede) Moisturizing gel in 1.5 oz tube, Moisturizing liquid in 1.5oz squeeze bottle
- moisturizing gel, especially useful at nighttime, liquid is for daytime use
- spread on tissues and under dentures as needed for long-lasting effects
- high patient acceptance, slightly sweet flavor, beneficial ingredients

C. SALIVA STIMULANTS
1. OVER THE COUNTER
Dentiva, OraMoist, Sal-Ese, Smart Mouth Mints and Xylimelts discs may give symptom relief
SalivaSure Tablets (fomerly called Salix SST by-Scandinavian Formulas, Inc.)-90 ct. bottle $8.95
- xylitol, citric acid, apple acid, Nacitrate, NaCMC, Dibasic calcium phosphate, colloidal silica
- buffered citric acid tablets for salivary stimulation without hard tissue demineralization
- order at www.scandinavianformulas.com- easy to carry, pleasant flavor, well-accepted by patients
- our most highly recommended product, no drug interactions or adverse effects

2. SYSTEMIC CHOLINERGIC AGENTS

For all cholinergic products:
titrate to minimum effective dose
potent cholinergic agonist -must counsel patients as to side effects and signs of toxicity
contraindicated in patients with narrow-angle glaucoma or cardiovascular disease as well patients on beta-
blockers (may cause conduction disturbance) or anticholinergics
use with caution in patients with gall stones, biliary tract disease, nephrolithiasis or pulmonary disease
prescribe in consultation with patients physician
RX: Pilocarpine 4% ophthalmic solution 4% solution = 1.3mg/drop, available in 15 ml bottles
Sig: Place 2-4 drops in 1-2 tablespoons of water, dose can be placed on sugarless gum
swish and swallow up to QID advantages: can titrate to effect, inexpensive ($12)

RX: Pilocarpine 5mg & 7.5 mg tabs (Salagen ) disadvantages: unscored tablet
Sig: 1 tab PO TID cant titrate to effect =the biggest disadvantage
very expensive (5mg $165/100 tabs, 7.5mg $205/100
NOW AVAILABLE GENERICALLY! tabs) generic is 30% cheaper

RX: Cevimelime (Evoxac) 30mg capsules new product more selective for receptors
Sig: Take one capsule BID-TID may be safer from cardiac standpoint expensive
giving with food extends action
$180/100 tabs

D. CARIES PREVENTION:
 OTC FLUORIDES:
- 0.02% rinse (from 0.05% NaF) - Act, Fluorigard
- 0.l% gels (from 0.4% SnF) - generics OTC, Gel-Kam & Stop are Rx, etc
- increased staining from SnF in xerostomic patients and acidic pH can be irritating
- fluoride concentration is equivalent to most OTC dentifrices
- we do not use stannous fluoride preps for xerostomic patients

PRESCRIPTION FLUORIDES (higher concentration):

- 0.09% rinse (from 0.2% NaF) - Fluorinse, Prevident, Neutracare, etc.
- 0.5% neutral gel (from 1.1% NaF) - Prevident, Neutracare, etc. - brush on or tray delivery
- Prevident 5000 Dry Mouth - combination mild dentifrice (RDA 87) & high potency fluoride
treatment (1.1% NaF) in a single product highly recommended for BID use in the xerostomics

Xylitol January 2013 JADA study on adult use of 1gram 5x daily was surprising!
-Previous studies on children showed benefit but definitive effect was inconclusive
E. SALIVA ENHANCEMENT OR MINERALIZING PRODUCTS

1) Novamin (calcium sodium phosphosilicate) by NovaMin

A synthetic mineral composed of calcium, sodium, phosphorous and silica, all elements naturally occurring in the body.
Silica (glass) containing Ca and PO is the driving mechanism that binds to the tooth surface

2) Recaldent (casein phosphopeptide-amorphous calcium phosphate)

Casein phosphopeptide and amorphous calcium phosphate (CPP-ACP)
Casein phosphopeptide is a milk protein peptide that is bound to amorphous calcium phosphate
3) Tri-Calcium Phosphate
4) Arginine Bicarbonate and Calcium Carbonate (Sensistat is now Colgate Pro-Argin)
Arginine bicarbonate is an amino acid complex found in saliva that is bound to calcium carbonate
Pro-Relief with Pro-Argin by Colgate
Proclude (Ortek) & Denclude (Ortek)

III. AGENTS CAUSING INCREASED GAG REFLEX

Statins used to manage hypercholesterolemia (Mevacor, Zocor, Lipitor, etc)
Potassium-sparing diuretics (triamterene, spironolactone, amiloride)
Cholestyramine (Questran, g) resin for hypercholesterolemia
Buproprion (Wellbutrin, g) antidepressant, anti-smoking

IV. DRUGS WITH DIRECT EFFECTS IN THE ORAL CAVITY

TOOTH DISCOLORATION (EXTRINSIC) stannous fluoride chlorhexidine iron preparations
(INTRINSIC) fluoride tetracyclines

BLACK HAIRY TONGUE

amitriptyline (Elavil) diazepam (Valium) nitrofurantoin (Macrodantin) tetracycline (Sumycin)
Amoxicillin (Amoxil) hydrogen peroxide nortriptyline (Aventyl)
cyclobenzaprine (Flexeril) ketoprofen (Orudis) PHENOTHIAZINES
clonazepam (Klonopin) lorazepam (Ativan) penicillin VK

GINGIVAL OVERGROWTH
amiodarone (Cordarone, Pacerone) ORAL CONTRACEPTIVES PHENYTOIN (DILANTIN,G)
cyclosporine (Sandimmune, Neoral) CALCIUMCHANNELBLOCKERS VALPROICACID(Depakene,Depakote

PIGMENTATION
busulphan (Myleran) HEAVY METALS (Hg, Pb) phenytoin (Dilantin)
bismuth (Pepto-Bismol) methotrexate (Rheumatrex) PROGESTINS
cyclophosphamide (Cytoxan) PHENOTHIAZINES senna
tetracyclines (Minocin, g) Hydroxychloroquine

SOFT TISSUE ULCERATION

ACE INHIBITORS carbamazepine ipratropium (Atrovent) potassium chloride
abacavir (Ziagen) cocaine iron salts warfarin (Coumadin)
actinomycin D (Cosmegen) Echinacea leflunomide (Arava) zalcitabine (Hivid)
alendronate (Fosamax) feverfew methotrexate (Folex, Rheumatrex) zidovudine (Retrovir)
ampicillin (Omnipen) flavoring oils modafinil (Provigil)
aspirin fluorouracil (Adrucil) NSAIDs
bleomycin (Blenoxane) genitian violet pancrelipase (Creon)

CONSEQUENCES OF IMMUNOSUPPRESSION bacterial, viral and fungal proliferation

Antibiotics: extended and broad spectrum antibiotics including cephalosporins and amoxicillin/clavulanate
Biologics: Anakinra(Kineret),Leflunomide(Arava), Methotrexate,Rituximab(Rituxan),Tacrolimus,Tocilizumab
Corticosteroids: systemic prednisone or methylprednisolone. Inhaled flunisolide, betamethasone, or triamcinolone
TNFIs: Adalimumab(Humira),Certilizumab(Cimzia),Etanercept(Enbrel),Golimumab(Simponi),Inflixumab(Remicade)

V. DRUGS AFFECTING TASTE AND SMELL

D= Dysgeusia-Altered taste M=Metallic Dysgeusia B=Bitter Dysgeusia
A=Ageusia-Absence or impairment of taste H=Hypogeusia-decreases sensitivity to taste S=Sweet Dysgeusia
 hyoscyamine (Anaspaz) A
5-flourouracil (Adrucil) D,S interferon-gamma A
Acebutolol (Sectral) D iodine M
acetazolamide (Diamox) D,B iron (various vitamins) D
allopurinol (Zyloprim) iron dextran (Dexferrum) M
amiloride (Midaamor)-to salt H isotretinoin (Accutane) A
amiodarone (Cordarone) D levamisole (Ergamisol) M
AMPHETAMINES levobupivacaine M
amphotericin B (Fungizone) D,H levoldopa (Dopar) D,H
amrinone (Inocor) D,H lincomycin (Lincocin) D
atenolol (Tenormin) D lisinopril (Prinvil, Zestril) D
auranofin (Ridaura) D,M lithium (Eskalith, Lithane) D,M
aurothioglucose (Solganal) D lomefloxacin A
azathioprine (Imuran) D lovastatin (Mevacor) A
azelastine (Astelin) D,B mazindol (Sanorex, Mazanor) D
baclofen (Lioresal) D mechlorethamine (Mustargen) M
BENZODIAZEPINES B, M metformin (Glucophage) D,M
benzphetamine (Didrex) D methimazole (Tapazole) D,A
BETA LACTAM ANTIBIOTICS M methocarbamol (Delaxin) M
betaxolol (Kerlone) D methotrexate (Folex) D
bisoprolol (Zebeta) D metronidazole (Flagyl) D,M,H
bleomycin (Blenoxane) D,A mexiletine (Mexitil) D
bretylium (Bretylol) D,H midazolam (Versed) D
brinzolamide (Azopt) B moricizine (Ethmozine) D
bromocriptine (Parlodel) M nadolol (Corgard) D
calcifediol (Calderol) M nicotine polacrilex (Nicorette) D
captopril (Capoten) D,M nifedipine (Procardia) D,A,H
carbamazepine (Tegretol) D,H nitroglycerin (Nitrostat) D
carboplatin (Paraplatin) M,H ofloxacin (Floxin) A
cartcolol (Cartrol) D ondansetron (Zofran) D
cefamandol (Mandol) D OPIATES A
chlorhexidine (Peridex) D,M,B,H penbutolol (Levatol) D
chloestyramine (Questran) D penicillamine (Cuprimine) D,M
chloline magnesuim trisalicylate (Trilisate,Tricosal)A pentamidine (NebuPent) M
cisplatin (Platinol) M,A,H phendimetrazine (Anorex, Bontril) D
clarithromycin (Biaxin) D pergolide (Permax) D
cloffibrate (Atromid-S) D phentermine (Ionamin) D
cromolyn sodium (Intal, Nasalcrom) D phenylbutazone (Butazoldin) D,A
dextroamphetamine (Dexedrine) D pindolol (Visken) D
diazoxide (Proglycem) D plicamycin (Mithracin) M
dicyclomine (Bentyl, Di-Spaz) A potassium iodide (Pima, Thyro-Block) M
diethylopropion (Tenuate) D procaine penicillin (Wycillin) D,M
diltiazem (Cardizem) D,B,H procainimide (Pronestyl) D
dipyridamole (Persantine) D propafenone (Rythomol) D,M
dolasetron (Anzemet) propranolol (Inderal) D,A
EDTA (Chealamide, Disotate, Endrate) D propylthiouracil (PTU) D,B,H
enalapril (Vasotec) D,A rifabutin (Mycobutin) A
encinide (Enkaid) D selegiline (Elderpryl) D
ethambutol (Myambutol) M selenium (Selepen) M
ethionamide (Trecator-SC) M spironolactone (Aldactone) D,B
etidronate (Didronel) M,A sulfasalazine (PTU) H
flecainide (Tambocor) D terbinafine (Daskil,Lamisil) A
flunisolide (AeroBid, Nasalide) A tetracycline (Achomycin) D,M
flurazepam (Dalmane) M timolol (Blocadren) D
fomepizole (Antizol) M tocainide (Tonocard) M
glycopyrrolate (Robinol) A tolbutamide (Orinase) D
granisetron (Kytril) D troazolam (Halcion) A
griseofulvin (Fulvicin) D vincristine (Oncovin) D
hydrochlorothiazide (Esidrix, Microzide, Oretic) A venlafaxine (Effexor) 2% D
VI. DRUGS CAUSING HALITOSIS
AMPHETAMINES DIURETICS lithium (Eskalith, Lithane)
ANTIHISTAMINES DMSO penicillamine (Cuprimine)
ANTINEOPLASTICS ethyl alcohol PHENOTHIAZINES
amyl nitrite garlic (non-dessicated) selenium
chloral hydrate (Noctec) griseolfulvin (Fulvicin) TRANQUILIZERS
disulfuram (Antabuse) isosorbide dinitrate (Isordil) xerogenic drugs

VII. IDIOSYNCRATIC DRUG ERUPTIONS

LICHENOID ERUPTIONS
ACE INHIBITORS chlorprompamide (Diabinese) PHENOTHIAZINES quinine (Formula Q)
acyclovir (Zovirax) furosemide (Lasix,g) SULFONYLUREAS tolbutamide (Orinase)
BETA BLOCKERS gold salts TETRACYCLINES tripolidine (Actagen-C)
carbamazepine HMG CoA Statins THIAZIDE DIURETICS
chloroquine (Aralen) NSAIDS quinidine (Duraquin, Cardioquin)

FIXED DRUG ERUPTIONS

BARBITURATES (Amytal, Seconal) SULFONAMIDES (Gantrisin, Gantanol, Bactrim, Septra)
chlordiazepoxide (Librium) TETRACYCLINES (Doxycycline, Minocycline, Tetracycline)

ERYTHEMA MULTIFORME
aspirin
acyclovir (Zovirax)
ampho B (Amphocin)
BARBITURATES
bupropion (Wellbutrin, Zyban)
carbamazepine (Tegretol)
clomiphene (Cloimid)
danazol (Danocrine)
diltiazem (Cardizem)
Echinacea
efavirenz (Sustiva)
enalapril (Vasotec)
meropenem (Meronem)
methazolamide (GlaucTabs)
methotrexate (Folex, Rheumatrex)
methylphenidate (Ritalin)
midodrine (ProAmatine)
nifedipine (Procardia)
ranitidine (Tritec)
sulfacytine (Renoquid)
sulfadiazine (Microsulfon)
SULFONAMIDES
tamoxifin (Nolvadex)
tetanus toxoid

DISSEMINATED LUPUS ERYTHEMATOSUS

hydralazine (Apresoline) isoniazid(INH) methyldopa (Aldomet) phenytoin (Dilantin)

VIII. DRUG-INDUCED MOVEMENT DISORDERS

Add/Adhd Drugs atomoxetine (Straterra ), Methylphenidate (Concerta, Metadate, Ritalin)
Antidepressants SSRIs (Prozac, Paxil, Zoloft, Celexa, Lexapro), TCAs (amitriptyline,nortriptyline), Lithium
Metoclopramide (Reglan), First and Second Generation Antipsychotics tardive dyskinesia

IX. OSTEONECROSIS OF THE JAW (ONJ) FROM BISPHOSPHONATES

Commonly Used Agents IV: pamidronate (Aredia), zoledronate (Zometa)-used for bone mets/hypercalcemia
ORAL:alendronate (Fosamax), Ibandronate (Boniva), Risedronate (Actonel)
IV: zoledronate (Reclast) once a year 5mg infusion for treatment of osteoporosis
SQ: denosumab (Prolia) is a 60mg every six months RANKL inhibitor. Effects on bone are reversible on d/c.
MOA-Bisphosphonates inhibit osteoclast precursors from attaching to the mineralized matrix which blocks transformation
into mature osteoclasts (bone-eroding cells). This allows osteoblasts (bone-building cells) to work.
ONJ Etiology Osteoclast formation is the first step in bone healing so this process is inhibited by bisphosphonates
ONJ Signs and Sx-undiagnosed pain, jaw numbness or heaviness, mucosa fails to heal, soft tissue swelling or infection
ONJ Risk Factors-dental extraction, dental infection or other trauma, drug therapy with corticosteroids, cancer
chemotherapy, intravenous bisphosphonates such as Zometa or Aredia, oral bisphosphonates (Fosamax, Actonel, Boniva)
ONJ Characteristics-exposed bone is very painful, swelling and loosening of teeth may be seen, debridement and surgical
correction exacerbate lesions, many cases are complicated by infection, primary risk is cancer patients on IV bisphosphonates
ONJ Prevention-avoid elective osseous surgery, recommend panoramic radiograph prior to tx., remove abscessed and
diseased tissue, dental prophylaxis and stabilization appropriate, ensure proper denture fit, oral hygiene self-care education
Treatment Modifications for Bisphosphonate patients-check and adjust dentures, aggressively manage dental infections
nonsurgically with endodontic tx or minimal surgery, endodontic therapy is far preferable to extractions when possible
ONJ Therapy-antibiotics, alcohol free chlorhexidine (Sunstar Butler), conservative debridement of sequestering bone
 XEROSTOMIA (Dry Mouth)
PATIENT INFORMATION HANDOUT
Karen A. Baker, R.Ph.,M.S., Associate Professor
The University of Iowa Colleges of Dentistry & Pharmacy
2014 Baker
DEFINITION:
Xerostomia (pronounced zero-stome-ah) is the medical word for dry mouth due to decreased or absent saliva.
This problem is quite common and is caused by a variety of medical conditions and medications.

HELPFUL HINTS:
Sip cool water throughout the day, let ice chips melt in mouth (dont chew ice!)
- most people do not drink enough fluids and this will contribute to a dry mouth
Try drinking 2% or whole milk with meals
- milk has moisturizing properties and helps some people to swallow their food
Restrict caffeine intake caffeine is a MAJOR cause of dry mouth. Use caffeine-free tea, coffee and sodas
- eliminating caffeine from your diet will have a significant effect on the symptoms of dry mouth
Use a cool air humidifier in the bedroom - clean and change water daily
- start the humidifier an hour or two before bedtime and let it run through the night
Avoid alcohol and alcohol-containing mouthwashes (read labels of commercial products carefully)
- alcohol can irritate the tissues and so can foaming agents like sodium lauryl sulfate (SLS)
Use sugar-free candy, gum and beverages, look for products that contain Xylitol (a sweetener that does not
cause cavities-IceBreakers Ice Cubes, Spry, Theragum, Epic are all high quality xylitol products)
- overuse of acidic candies and foods can cause a sore mouth
- chewing gum will stimulate saliva flow but look for 6g/.day of xylitol
For dry lips,use hydrous lanolin USP (Lansinoh),Banana Boat Aloe with Vitamine E lip balm, or Blistex Herbal
Answer during the day and especially at bedtime. Chronic use of Vaseline is drying and should be avoided.
If possible, sleep on your side in order to reduce mouth breathing
See your dentist frequently
- people with dry mouth are more prone to oral yeast infections as well as dental cavities
- excellent oral hygiene is necessary to prevent cavities and gum disease

COMMERCIAL SALIVA SUBSTITUTES, STIMULANTS & MOISTURIZING GELS

The products listed below are available without a prescription and can be found or ordered from many pharmacies.
These products are very helpful in alleviating the symptoms of dry mouth. They can be used as often as needed,
do not interfere or react with other prescription drugs and do not have side-effects.

TABLETS:
SalivaSure Tablets (formerly called Salix SST by Scandinavian Formulas, Inc.) 90 ct. bottle $7.95
- to stimulate natural saliva flow, dissolve one tablet slowly under tongue up to every hour as needed
- highly recommended, will not cause cavities or sore mouth
- easy to carry, mild mint flavor, no drug interactions
- may be difficult to obtain but ask your pharmacist to order the product.(Walgreens cant order it)
GEL:
Oral Balance (GSK) - 1.5 oz tube
- moisturizing water based gel, especially useful at nighttime
- spread on tissues and under dentures as needed for long-lasting effects

TOOTHPASTE:
Biotene Toothpaste(GSK) 4.5 oz tube only available in the Fresh Mint Gel right now
- also available in a gel formulation in a green box, contains MFP fluoride

SALIVA SUBSTITUTE LIQUID:

Saliva Substitute -4oz(Roxane) or Oasis -1oz (GSK) mouthspray
Oral Balance Dry Mouth Moisturizing Liquid-1.5oz(Laclede)
- Stoppers4 Dry Mouth Spray -1oz(Woodridge Inc.)
 PRODUCTS FOR MANAGING ORAL MALODOR
I. CAUSES OF ORAL MALODOR

A. Non-oral causes
-Systemic Sources diabetes, high protein/low carb diets, renal or hepatic failure, sinus
infections, internal bleeding
-Medications that cause malodor Antabuse, DMSO, Griseofulvin, Isosorbide dinitrate
-Xerogenic Medications antidepressants, antihypertensives, CNS stimulants, narcotics

B. Dental Causes of oral malodor

-Gingivitis, periodontitis, gross carious lesions, subgingival/tongue plaque, tonsilloliths
-Bacteria include Treponema denticola, Porphyromonas gingivalis, Prevotella intermedia,
Tannerella forsythensis, Porphyromonas endodontalis, and Eubacterium species

II. TESTING FOR ORAL MALODOR

A. Organoleptic Testing sniff or smell patients mouth and nose air-scale 0-5
B. Halimeter by InterScan (Chatsworth, CA) is an electronic nose for VSCs

III. TREATMENT FOR ORAL DISEASES TONGUE CLEANERS

A. Orafresh Tongue Blade pediatric and adult sizes, Alwin Enterprises, 800.749-4553
B. Oolitt bendable and low profile loop cleaners, Deep Trading Corp, 813.931.0390
C. Denteco disposable razor-like, Denteco, Inc., 508.755.0804
D. Dr. Weiders tung brush and gel, Peak Enterprises, www.tungbrush.com
E. Dr. Tungs stainless steel arch/padded grippers or single handed, Dr.Tungs
F. Vista disposable razor-like, Vista, Inc., 414.636.9755
G. Sakool bendable plastic rod, U.S. Dentek Corp., 800.433.6835

IV. CHEMICAL PRODUCTS EFFECTIVE FOR ORAL MALODOR REDUCTION

A. Zinc Salts (chloride, citrate, acetate) sustained breath odor reduction for 3 hours

a. Toothpastes TriOral, Listerine Tartar Control, Viadent Advanced Care, Aim TC, Close-Up
TC, Kiss My Face Tartar Control, Smart Mouth Toothpaste

b. Mouthwashes Lavoris, Listermint, Listerine Tartar Control

B. Chlorine Dioxide (sodium chlorite) sustained breath odor reduction for 5 hours

a. Toothpastes Oxyfresh, CloySys II, Therabreath, Profresh,

b. Mouthwashes Oxyfresh, CloSys II, Therabreath, Enfresh, Profresh

C. Essential Oils of Listerine (menthol, thymol, eucalyptol) sustained breath odor reduction for 3 hours

a. Toothpastes Listerine EC paste and gel, Breath-So-Fresh Toothpaste

b. Mouthwash Listerine EC Mouthwash, many store brands

D. Combinations of two of the above effective ingredients

a. Smart Mouth chlorine dioxide and zinc chloride mouthwash www.smartmouth.com

b. Breath-So-Fresh essential oils and zinc chloride
c. Oxyfresh with Zinc chlorine dioxide and zinc chloride www.badbreathcenter.com
 V. Product Lines Promoted for Halitosis Treatment

CHEMICAL MANUFACTURER PRODUCT LINE/CHARACTERISTICS

COMBINATIONS
1.) Chlorine Dioxide & Zinc
TheraBreath TheraBreath Global
www.therabreath.com
Oxyfresh Oxyfresh Worldwide Inc.
www.oxyfreshww.com
Breeze BreezeCare
www.breezecare.com
KFORCE BreezeCare
ProFresh ProFresh
www.profresh.com
CloSYSII Rowpar Pharmaceuticals Inc.
www.rowpar.com
EnFresh www.enfresh.com
BreathGel International Dental Design
Specialist, Inc.
TriOral Professional TriOral
SmartMouth Retail www.trioral.com
www.smartmouth.com
2.) Zinc Compounds
BreathRx (CPC and Zinc rinse, Philips acquired Discus Dental
zinc toothpaste) www.philipsoralhealthcare.com
Arm & Hammer P.M. Church & Dwight Co.
TriOral Action TriOral
3.) Essential Oils
Listerine Johnson and Johnson
www.listerine.com
TheraBreath TheraBreath Global
4.) Triclosan
Colgate Total Series Colgate-Palmolive
5.) Naturals/Herbals
Good Breath Scandinavian Formulas
Healthy Teeth and Gums The Natural Dentist
www.thenaturaldentist.com
Tooth & Gum Tonic Dental Herb Company
Toms Natural Toms of Maine
Desert Essence Tea Tree Oil Country Life
Toothpaste, Oral Rinse, Breath Strips, Chewing
Gum, Zox Mints, Mouth Sprays
Toothpaste-Flouride/Non-Flouride, Mouth rinse,
Dental Gel, Breath Mints, Tongue Scraper, Relief
Gel
Toothpaste, Breath Strips, Mouthrinse
Pre-Rinse, Mouthwash, Lozenges
Mouthwash-0.003%
Toothpaste, Oral Spray, Oral Rinse
Trizox compound, Tongue gel, tongue brush,
mouth rinse
ZyClor compound, tongue cleaner, mouth rinse
Mouthrinse in two 473ml bottles. The green bottle
is zinc and the white bottle is chlorine dioxide.Now
travel packets and toothpaste.
Mouthwash,toothpaste,gumballs,mints,spray and
tongue cleaner
Toothpaste
Toothpaste, Gum, Mints
Toothpaste, Mouthwash, PocketPaks Pocket Mist,
Breath Strips
Rinse,Breath Strips,Gum,Toothpaste,Kit
Toothpaste
Soft Gel Tablets
Toothpaste, Oral rinse
Oral rinse, dentifrice
Mouth rinse, toothpaste
Mouth spray, tea tree ingredient found also found
in toothpaste, mouthwash

V. STEPWISE APPROACH TO TREATMENT OF ORAL MALODOR

A. Good subgingival plaque control and twice daily tongue cleaning NOT BRUSHING!!

B. Add zinc toothpaste twice daily. Increase zinc use with mouthwash as needed

C. Switch mouthwash to chlorine dioxide if response is not adequate to B.

D. Switch to chlorine dioxide toothpaste and a combination of chlorine dioxide and zinc
mouthwash if C is not adequate. Maintain twice daily tongue cleaning.
 Therapeutic Agents and Treatment Strategies for the Management
of Selected Mucosal Diseases
Spring 2016
Faculty, Dept. of Oral Pathology, Radiology & Medicine
The University of Iowa College of Dentistry
Footnote Key:
1. These medications are all contraindicated in microbial diseases. If given to patients with microbial diseases, microbial
proliferation is usually enhanced and systemic dissemination is possible. Candidosis is a common side effect.
2. Systemic steroids are contraindicated or must be used with caution in a number of systemic conditions. Consultation with the
patient's physician is recommended before prescribing. Tapering of prednisone is not necessary with 5-7 day burst therapy.
Tapering of prednisone is not necessary with alternate day therapy (QOD) if the dosage does not exceed 20 mg QOD. In order to
reduce the possibility of adrenocortical suppression, it is important that prednisone be taken in harmony with diurnal
adrenocortical steroid levels. In order to accomplish this, prednisone should be taken 1-1/2 hours after normal arising time.
Alternate day AM (QOD) dosage also reduces the possibility of adrenocortical suppression.
3. Whenever topical mouth rinses or ointments are prescribed, the manner in which the medication is used is very important.
The patient should be advised that the medications are effective on contact and that they should avoid anything by mouth (NPO)
for 1/2-1 hour after using them to prolong medication contact time.
4. Baseline hematology laboratory studies to include platelets are necessary to monitor possible bone marrow suppression.
5. Hepatotoxicity has been reported. OPRM Faculty

* Denotes prescription items that must be extemporaneously compounded by a pharmacist. Usually a specialty "compounding
pharmacy" is a better choice as they have more experience and knowledge regarding product formulation.

Extemporaneously Compounding Medications for Intraoral Conditions

Few products available in the U.S
Limited product demand???
- Problems - Difficulty with insurance payments, XIX & Medicare will not reimburse for the full cost of
compounded prescriptions &I can do that - generalized lack of knowledge
- Make sure products are not flavored or sweetened (especially with sucrose) unless necessary!

I. CHRONIC NON-MICROBIAL MUCOSITIS

(aphthous stomatitis, erosive lichen planus, mucous membrane pemphigoid, pemphigus, erythema multiforme)

Mouth rinses: Magic mouth rinse, Miracle mouth rinse, 1,2,3 Special mouth rinse formulas, etc.
DONT bother!! WHY:
Nystatin 12,500 units/ml
- Normal nystatin 100,000/ml
- 8 fold decrease from our minimum therapeutic agent
Benadryl 1.25 mg/ml
- 7.5 mg fairly low dose too
- 25 mg much more commonly used
- Does give a topical anesthetic effect at least in the higher concentrations
Hydrocortisone
- Hydrocortisone 0.25 mg/ml
- 10 fold decrease from dexamethasone 0.5mg/5ml
- 20 fold decrease from 0.1% triamcinolone acetonide suspension
Kaopectate
-
Many older formulas use the attapulgite clay in Kaopectate to coat the mucosa. This product has been
reformulated and now contains bismuth subsalicylate, which can cause a grayish-black discoloration of the
tongue and is contraindicated in patients with hypersensitivity to salicylates.

1|P a g e
Baseline initiatives to allow therapies to work:
Decrease common possible irritants Avoid: Maintain saliva
- Pyrophosphates - Xerogenic agents
- Cinnamon - Hydration
- Menthols, phenols, etc. Manage bugs
Maintain salivary pellicle - Bacteria
- Avoid sodium lauryl sulfate (SLS) - Fungi
- Avoid EtOH if possible

Mouth rinses1,3
1
RX: Dexamethasone 0.5 mg /5 ml oral solution Commercial version
Disp: 240 ml Covered by Medicare Part D and HMOs in general
Sig: Rinse with 5 ml for 1 min. and expectorate QID, PC Watch ethanol % in brands- Roxane brand is EtOH free
(after meals) and HS (before retiring). NPO 1\2 hr Use correct strength to avoid toxicity

RX: Triamcinolone acetonide () 0.1 OR 0.2% About 2 x stronger than the commercial dexamethasone
1
aqueous suspension Use the 0.2% for more severe cases
Disp: 240 ml 4 cc 95% EtOH per 240 ml
Sig: Rinse with 5 ml for 1 min. and expectorate QID, PC Best if made with micronized powder () vs. commercial
(after meals) and HS (before retiring). NPO 1\2 hr. injectable suspension (also much less expensive)

RX: Triamcinolone acetonide () 0.1 OR 0.2% Use in patients predisposed to candidosis

in nystatin 100,000 U/ml suspension Commercial nystatin suspension is 30-50% sucrose
Disp: 240 ml We make a sugar-free nystatin suspension at the COD
Sig: Rinse with 5 ml for 1 min. and expectorate QID, PC
(after meals) and HS (before retiring). NPO 1\2 hr

RX: Triamcinolone acetonide () 0.1 OR 0.2% Use in patients predisposed to candidosis

in amphotericin-B 15mg/ml suspension Our amphotericin-B suspension is sugar-free
Disp: 240 ml More efficacious than nystatin suspension
Sig: Rinse with 5 ml for 1 min. and expectorate QID, PC and Use amphotericin-B 25 mg/ml if needed
HS. NPO 1\2 hr.

Ointment 1, 3

RX: Triamcinolone acetonide 0.1% OR 0.5% ointment Low to medium potency steroid, price $18
Disp: 15 gm Use 0.1% strength on lips and dermis
Sig: Apply thin film to inner surface of dentures or Still fluorinated and can thin lips or dermis long term
medication trays up to QID, NPO 1/2 hr. Choose desonide instead for chronic use
We usually use higher potency steroids in trays Seat trays for 30 min., then rinse mouth

RX: Fluocinonide 0.05% OR clobetasol 0.05% ointment Commercial products

Disp: 15 gm High potency steroids
Sig: Apply thin film to inner surface of dentures or Instruct patients to expectorate & rinse mouth
medication trays BID. Seat for 30 minutes thoroughly after use
Price of commercial products $100-190 for 15 g tube

2|P a g e
Occlusive Ointment 1, 3

RX: Triamcinolone acet. 0.5% ointment 1:1 with Orabase contains benzocaine. Allergenicity?
Orabase Lower potency mixture due to 1:1 dilution
Disp: 30 gm Prescribe ointments to mix with Orabase (never
Sig: Apply thin film to dried mucosa BID-QID, PC & creams)
HS Do not rub in. NPO 1/2 hr. Rubbing causes the Orabase to become grainy &
lose elasticity RPh must mix ingredients very
gently to avoid a grainy/ineffective product

RX: Clobetasol .05 % ointment 1:1 with Compounded clobetasol ointment mixed 1:1 with
Orabase Orabase
Disp: 30 gm Use higher concentrations of clobetasol ointment for
Sig: Apply thin film to dried mucosa BID. Do not rub recalcitrant lesions
in. NPO 1/2 hr.

RX: Triamcinolone 0.1% in Orabase Commercially available but cost to patient

Disp: 5 gm tube approximately $80 per 5 gram tube!
Sig: Apply thin film to dried mucosa QID. Do not rub Low concentration of triamcinolone
in. NPO 1/2 hr Good bandage effect, useful in pediatric patients

Combined Anti-inflammatory & Antimycotic Topical Agents 1

RX: Clotrimazole 1% cream mixed 1:1 with triamcinolone For patients prone to candidosis
acetonide 0.5% oint. Dilution factor is a potential problem
Disp: 30 gm Most retail pharmacies will compound these 1:1
Sig: Apply thin film inner surface of dentures or type of compounds, no clotrimazole oint. on market
medication trays BID. Seat for 30 minutes. In reality no pharmacies are going to mix the
clotrimazole oint b/c the insurance companies wont pay
for it

RX: Clobetasol 0.03%, clotrimazole 2% ointment Compounded from drug powders (not a 1:1 mixture)
Disp: 10, 20 or 40 gm Allows for 2x commercial strength of clotrimazole
Sig: Apply thin film inner surface of dentures or Can customize strengths of both agents
medication trays BID. Seat for 30 minutes. Ointment formulation is more occlusive than creams

Systemic and Intralesional Steroids

1, 2
RX: Prednisone 5 mg, 10 mg, 20 mg tabs Dose range 40-80 mg per day, depending on
Disp: # professional judgment; generally for severe acute
Sig: 40mg PO q A.M. (1-1/2 hrs after normal arising cases such as erythema multiforme or initial therapy
time) x 5 days followed by 10 mg QOD A.M. x 10 days for long term unmanaged pemphigus, lichen planus
Short bursts < 3 weeks dont require taper or pemphigoid
Best taken with food When daily dose is 30 mg or greater patients may
experience insomnia, headache or irritability

RX: Triamcinolone acetonide injectable 40 mg/ml Best mixed with local anesthetic with epinephrine as
(Kenalog) diluted to 10 mg/ml or use Kenalog the diluent
10 mg/ml strength
1
Area should be anesthetized before injection of
3|P a g e
Directions: Inject 10-40 mg (shake syringe immediately before use) triamcinolone acetonide suspension if local anesthetic
Of value in management of solitary lesions recalcitrant to is not used.
topical or systemic steroids

II. BENIGN MUCOUS MEMBRANE PEMPHIGOID

Anticollagenase Agents

RX: Doxycycline hyclate or minocycline 50-100 mg tabs/caps Use as an adjunct to steroid therapy
Disp: #30 Avoid taking with antacids, iron, calcium tablets
Sig: Take QD or BID with food and plenty of water. Nicotinamide has similar actions but requires close
Avoid taking HS esophageal irritant monitoring by a specialist
Doxycycline $100, minocycline $50
FDA pregnancy category: D

III. APHTHOUS STOMATITIS

Pathophysiology: Immunologic
Location: nonkeratinized, unattached mucosal surfaces
- Typically buccal vestibule, lateral or ventral tongue, floor of mouth
Heals in a predictable manner
- Types: minor, major, herpetiform
- Treatment not usually necessary for the common minor type
Precipitating Factors:
Cinnamon Oil Genetics Minor Oral Trauma
Medications Stress Dentifrices
Sodium Lauryl Sulfate (SLS) Estrogen Shifts
Primary Prevention Factors: Relate to maintenance of salivary pellicle or impeding the recognition of antigens to the immune system
Pharmacotherapeutic Management Choices:
Topical Route
- Treatment of choice: triamcinolone acetonide rinse - alters course of disease, increases healing rates
- Steroid ointments, pastes
Systemic Route
- Prednisone - for difficult cases, large +/or multiple ulcerations
Over-The-Counter Products
Inappropriate Chronic Treatment
- Cautery agents - do not affect course of disease (Debacterol, silver nitrate, Negatan, laser)
- Tetracycline rinses, oral antibiotics etc.
Sodium Lauryl Sulfate (SLS) Free Dentifrices
Note: All SLS free products are not appropriate for some patients due to pyrophosphate content
- Prevident 5000+ Dry Mouth, 100 g container (only SLS free Prevident product)
- Biotne (GSK) Fresh mint original (other Biotnetoothpaste is gentle mint this formulation can be irritating)
- Toms of Maine Peppermint Clean and Gentle Fluoride Toothpaste
- Sensodyne: Original, Pronamels
- Squigle Enamel Saver (with NaF) or Tooth Builder (with no fluoride and 40% xylitol)

IV. CANDIDIASIS

Topical Suspensions 3

RX: Nystatin oral suspension 100,000 U/ml Commercial products contain 33-50% sucrose, not a
Disp: 14 day supply (240 ml) first-line choice for this reason, especially in
Sig: Rinse with 5 ml for 1 minute and expectorate P.C. chronic/recurrent cases like Sjgrens, medicament
(after meals) and HS (before retiring) NPO 1/2 hr. xerostomia or post radiation xerostomia, $60/240 ml
4|P a g e
RX: Nystatin oral susp. 100,000 U/ml Sugar-Free Viscous, will coat tissue
Disp: 14 day supply (240 ml) Must be refrigerated, shorter shelf life than
Sig: Rinse with 5 ml for 1 minute and expectorate P.C. commercial, but not cariogenic
(after meals) and HS (before retiring) NPO 1/2 hr.

RX: Amphotericin-B oral suspension 25mg/ml Much more effective than nystatin suspension
Disp: 14 day supply (280 ml) Of use for fluconazole-refractory infections or when C.
Sig: Rinse with 5 ml for 1 minute and expectorate P.C. krusei or C. glabrata are suspected
(after meals) and HS. (before retiring) NPO 1/2 hr. May use 15mg/ml strength when combining with
triamcinolone acetonide

RX: Clotrimazole 10 mg/ml gel Useful for debilitated patients who cannot rinse
Disp: 30 g Compounded with clotrimazole powder and Biotne
Sig: Swab thin film onto affected area QID, PC Oral Balance Gel (GSK)
and HS, NPO 1/2 hr.

Ointment 3

RX: Nystatin ointment 100,000 U/g Inexpensive, but poor antifungal

Disp: 15 gm Works OK under dentures, but not first line agent
Sig: Apply thin film to inner surfaces of dentures and Bright yellow color may be objectionable for angular
angles of mouth QID, PC & HS. NPO 1/2 hr. cheilitis, $18

Cream 3

RX: Clotrimazole 1% cream (Rx, OTC as Lotrimin AF, g) Has slight anti-staph activity
Disp: 15 gm Rx or 12 gm OTC Available OTC ($7) but labeled for athletes foot and jock
Sig: Apply thin film to inner surface of denture and itch which may cause some patients to hesitate.
angles of mouth QID. NPO 1/2 hr. after use. Identical product as Rx version ($18)

Lozenges and intraoral tablets 3

RX: Clotrimazole 10 mg oral troches Compliance problems with 5X daily therapy

Disp: 70 troches 1 troche QD HS or BID is useful for maintenance or
Sig: Dissolve 1 troche in mouth every 3 hours while awake prevention. $70-100
(5 tabs per day). NPO 1/2 hr. after use. FDA pregnancy category: C

Systemic 5

RX: Fluconazole 100 mg tablets Dose-related interactions with statin drugs,

Disp: #11-15 tabs benzodiazepines, sulfonylureas, warfarin and some
Sig: Take 1 tablet BID for first day, then take 1 tablet daily for 10 antihpertensives and many other drug classes always
14 days. check for interactions before prescribing
Cost of 15 tablets is approximately $50.00, cheaper to FDA pregnancy category: D
break 200 mg tablets in half

5|P a g e
Antibacterial Mouthrinse 3

RX: Chlorhexidine 0.12% oral rinse (Peridex, g) 11.6% alcohol content will irritate ulcerations and
Disp: 473 ml enhance xerostomia, $13
Sig: 10 - 15 ml mouthrinse for 30 seconds and expectorate Due to chemical deactivation, separate from toothpaste
BID (after breakfast and HS, NPO 1\2 hr. by 30 min.
FDA pregnancy category: B

RX: Alcohol-Free Chlorhexidine 0.12% oral rinse (Paroex)

Disp: 473 ml Non-alcohol formulation useful for alcoholics, patients
Sig: 10-15 ml mouthrinse 60-90 seconds and expectorate with mucositis, xerostomia, $18
BID, PC, AM & HS. NPO 1/2 hr. Due to chemical deactivation, separate from toothpaste
by 30 min.

V. HERPES & HERPES ZOSTER INFECTIONS

Herpes Labialis (Cold Sores, Fever Blisters)

Virus remains dormant within the dorsal root ganglia until activated
Asymptomatic viral shedding occurs for several days before the prodromal period & after lesions heal
Specific triggers:
- Sunlight (ultraviolet radiation) UVB
- Tissue injury & inflammation
- Physical or emotional stress: malnutrition, fever, colds, influenza, menstruation, exposure to extremes in temperature

Systemic Treatment of Herpes Labialis (Immunocompetent Patients)

RX: Valacyclovir 1 g tablets (Valtrex, g)

Disp: 4 tablets A prodrug of acyclovir which is 3 times more bioavailable
Sig: 2 tablets at onset of symptoms, then 2 tablets than acyclovir, may use in patients > 12 years of age
12 hours after first dose WARNING: Use with caution in renal & hepatic disease,
Drug of choice -probably most efficacious therapy to date has not been studied in pre-pubescent children
Price of 4 tablets $20 Headache &/or nausea are dose related side effects (15%)
FDA pregnancy category: B

RX: Famciclovir 500 mg tablets (Famvir, g)

Disp: 3 tablets Best taken within 48 hours of symptom onset
Sig: Take 3 tablets (1500 mg) at onset of prodome Can cause headaches, dizziness, GI upset
Symptom duration decreased by 1.7 days when taken Efficacy & safety havent been established in patients
within an hour of onset of prodome under 18 years of age, adjust dosage in renal impairment
nd
Price of 3 tablets $30, not available in all pharmacies 2 line therapy after Valacyclovir
FDA pregnancy category: B

Topical Treatment of Herpes Labialis (Immunocompetent patients)

Topicals are MUCH less efficacious than oral (systemic) therapy, prohibitively expensive and not recommended but included
here for completeness. Note: Topical creams and ointments are not appropriate for intraoral use

We do not recommend topicals due to ineffectiveness and exteme expense of the Rx topicals

6|P a g e
OTC: Docosanol 10% cream (Abreva) Recurrent HSV labialis studies (2) demonstrate mean
2 gm tube duration of lesions & pain by to 1 day
Directions: Apply 5 times daily at onset of symptoms until ??? Efficacy compared to other topicals
lesions heal $20/2 g tube

RX: Penciclovir 1% cream (Denavir) Recurrent HSV labialis studies (2) demonstrate mean
Disp: 5 gm tube duration of lesions & pain by 1 day.
Sig: Apply every 2 hrs during waking hours for 4 days More efficacious than acyclovir ointment
beginning at the onset of symptoms Cost: >$815/5 g tube

RX: Acyclovir 5% cream (Zovirax) or ointment Little benefit, duration of Sx. decreased by day
(Zovirax,g) 5 g tube of Zovirax cream $800, 5 g tube of generic oint. $140
Disp: 5 gram tube cream (Zovirax) 5 gram tube ointment Recurrent HSV labialis shows no clinical benefit, but some
Sig: Apply thin film every 3 hrs (at least six times daily) at in viral shedding
the onset of symptoms Is NOT effective in prevention of recurrent herpes labialis

Systemic Agents for Primary & Recurrent HSV Gingiviostomatitis (Immunocompetent Patients)

Acute herpetic gingivostomatitis can occur on both movable and attached oral mucosa. Recurrent infections in healthy patients
are usually limited to attached gingival and hard palate
It is important to note that the duration of treatment for a primary case of HSV gingivostomatitis vs a recurrent case is different.
Recurrent cases require shorter durations of treatment!!!
Short term therapy is indicated for patients who get recurrent herpetic after prolonged sun exposure, dental treatment, etc.
Therapy must be initiated before exposure to any triggers. Start the day before trigger exposure and continue for a full
course of treatment as listed below.

RX: Valacyclovir 500 mg or 1 g (Valtrex, g) caplet WARNING: Use with caution in renal & hepatic disease, has
Primary HSV Gingivostomatitis : not been studied in pre-pubescent children
Sig: 1 gram BID x 7-10 days Headache & nausea are dose related side effects (15%)
Recurrent HSV Gingivostomatitis:
Sig: 500mg BID x 3 days Or 1 g once daily x 5 days

Can cause headaches, dizziness, GI upset

RX: Famciclovir 250 mg or 500 mg tablets Best taken within 48 hours of symptom onset
Primary Gingivostomatitis HSV: Efficacy & safety havent been established in patients under 18
Sig: 250 mg TID x 7-10 days years of age
Recurrent Gingivostomatitis HSV:
Sig: 1000 mg BID x 1 day Or 125 mg BID x 5 days

RX: Acyclovir 400 mg (Zovirax, g) tablet Only effective if initiated very early in recurrence
Primary HSV Gingivostomatitis: WARNING: Use with caution in renal function impairment,
Sig: 400 mg 3 times daily for 7-10 days dehydration
Recurrent HSV Gingivostomatitis: FDA pregnancy category B
Sig: 400 mg 3 times daily for 5 days Primary gingivostomatitis in children: Acyclovir 15 mg/kg PO 5
Or 800mg 3 times daily for 2 days times daily for seven days (maximum of 1000 mg/day)

7|P a g e
Prophylaxis for Recurrent HSV Infections (Immunocompetent Patients)

Prophylaxis for recurrent herpes labialis (RHL) and gingivostomatitis using oral antivirals:
Long term prophylaxis is indicated if patients have at least six or more herpetic outbreaks per year. Reassess need every 6
12 months.

RX: Acyclovir 400 mg (Zovirax, generic) Must be given in divided doses

Disp: 60 tablets Prophylactic doses between 800-1600 mg/day reduces
Sig: Take 400 mg BID the frequency of herpes labialis by 50 78%

RX: Valacyclovir 500 mg (Valtrex, generic) Doesnt appear to have large advantage over acyclovir
Disp: 30 caplets Regimen for patients with >9 episodes/year is 1 gram QD
Sig: Take 500 mg daily

RX: Famciclovir 500 mg (Famvir, generic) No evidence that Famciclovir prevents RHL
Disp: 30 tablets
Sig: Take 500 mg BID

Varicella Zoster Virus (VZV) Infections

25-fold decrease in zoster after immunization

Patients with prior varicella zoster virus infection have a 20% chance of acquiring shingles

Trials showing benefit of Rx therapy only in patients treated within 3 days of onset of rash:

RX: Valacyclovir 1 gram (Valtrex, generic) Patients should begin treatment within 72 hours of the
Disp: 21 caplets onset of symptoms.
Sig: Take 1 caplet TID for 7 days More effective than acyclovir for cessation and duration of
Drug of choice post-herpetic neuralgia
WARNING: Use with caution in renal & hepatic disease

RX: Famciclovir 500 mg (Famvir, generic) Patients should begin treatment within 48 hours of onset
Disp: 21 tablets of symptoms, efficacy after 72 hours is questionable
Sig: Take 1 tablet every 8 hours for 7 days WARNING: Use with caution in renal function impairment,
Prodrug of penciclovir, approximately same efficacy and has not been studied in children <18 years of age
safety as acyclovir Equivalent to acyclovir in the duration of acute pain

RX: Acyclovir 800 mg (Zovirax, generic) Therapy is most effective if started within 48 hrs after
Disp: 35 - 50 tablets the onset of symptoms
Sig: Take 1 tablet q 3 hours while awake (5 In our experience, oral acyclovir has been of value in
tablets per day) for 7-10 days controlling the epidermal and mucosal lesions due to
herpes zoster. It has not had major effect on the pain
associated with herpes zoster

8|P a g e
 Drug Interactions Important in Clinical Dentistry
2016 K. Baker
DENTAL DRUG INTERACTING DRUG
ANTIBIOTICS
Penicillins
All Penicillins Bacteriostatic antibiotics
(clindamycin, erythromycin, tetracyclines)
Rare decrease in OC effectiveness with Methotrexate (Rheumatrex, g)
>48 hour
Oral contraceptives
s of antibiotic therapy. Recommend
additional barrier contraception for the
remainder of the Pill package. Probenecid (Benemid, g)
Ampicillin Allopurinol (Zyloprim, g)
Atenolol (Tenormin, g)
Cephalosporins
All Agents Anticoagulants (Coumadin, g)
Bacteriostatic antibiotics
(clindamycin, erythromycin, tetracyclines)
Probenecid (Benemid, g)
Cefdinir (Omnicef) Increased gastric Ph.
Cefpodoxime (Vantin) (Antacids, Axid, Pepcid, Prilosec, Tagamet,
Cefuroxime (Ceftin) Zantac)
Lincomycins
Clindamycin (Cleocin, g) Erythromycin
Kaolin-Pectin
Succinylcholine (Anectine)
Macrolides/Azalides Alfentanil
Azithromycin (Zithromax,Zpak,g) only agent that Anticoagulants (Coumadin, g)
does not inhibit CYP450 3A4 but DOES prolong
QT interval so only QT prolongation interactions Benzodiazepines (alprazolam, diazepam,
apply to Azithromycin triazolam)
dirithromycin (Dynabac)
clarithromycin (Biaxin, Biaxin XL, g)
erythromycin (base, EC, EES, PCE)
Bromocriptine (Parlodel)
CCBs (diltiazem (Cardizem,g) and verapamil
(Isoptin, Calan, Verelan,g)
Carbamazepine (Tegretol, g)
Clindamycin
Cyclosporine (Sandimmune, Neoral)
Digoxin
Disopyramide (Norpace, g)
RESULT/MANAGEMENT
Static agent may impair action of penicillins.
Consult with other prescriber for modification.
High dose penicillins may decease MTX
secretion. Monitor MTX.
Rare decrease in estrogen effect. Use barrier
contraception for duration of pill cycle.
Tubular secretion of penicillins may be
decreased. Usually not problematic.
Doubling in rate of ampicillin rash with
concurrent administration (14-22%)
Atenolol bioavailability may be reduced.
Risk of bleeding disorders might be increased
in anticoagulated patients.
Use cautiously.
Static agent may impair action of
cephalosporins. Consult with other practitioner
for modification.
Tubular secretion of penicillins may be
decreased. Usually not problematic.
Reduced absorption of the cephalosporins.
AVOID CONCURRENT USE.
Possibility of antagonism. AVOID
CONCURRENT USE.
Delay in clindamycin absorption with
concurrent use.
Possibility of prolonged respiratory
depression. Monitor patient.
Alfentanil actions increased. Use caution.
Risk of bleeding disorders is increased in
anticoagulated patients. Monitor pt.
Increased benzodiazepine levels resulting in
CNS depression. Avoid combination in elderly.
Increase in bromocriptine toxic effects.
Consult MD.
QT interval prolongation, sudden death,
AVOID CONCURRENT USE
Increased carbamazepine levels. Avoid
concurrent use. Azithromycin is okay.
Possible antagonism. AVOID COMBINATION.
Increased cyclosporine renal toxicity. Consult
MD.
Increased digoxin levels in 10% of patients.
May use cautiously.
Increased disopyramide levels may cause
arrhythmias. Use cautiously.
Macrolides All Age Ergotamine
Methylprednisolone
Omeprazole (Prilosec)
Penicillins
Pimozide (Orap)
Statins (Lipitor,Zocor, Mevacor)
Theophyllines
Tolterodine (Detrol)
Metronidazole (Flagyl, Flagyl ER, Prostat, g) Anticoagulants (Coumadin)
Barbiturates
Cholestyramine (Questran, g)
Cimetidine (Tagamet, g)
Disulfuram (Antabuse)
Ethanol (IV diazepam, IV TMP-SMZ)
Lithium
Phenytoin (Dilantin)
Quinidine
Tacrolimus (Prograf)
Tetracyclines
Antacids containing Al,
All Agents calcium, magnesium
(doxycycline, minocycline, tetracycline)
Bismuth (Pepto-Bismol)
Iron Salts
Oral Contraceptives
Doxycycline (Vibramycin, Periostat??) Carbamazepine (Tegretol)
Methotrexate (highdose IV)
Phenobarbital
Phenytoin (Dilantin, g)
Tetracycline (Sumycin, Panmycin) Colestipol (Colestid)
Food (Milk and Dairy)
Zinc sulfate
Quinolones
All Agents: Antacids
Ciprofloxacin (Cipro,g) (iron, sucralfate, zinc)
Gatifloxacin (Tequin) Anticoagulants (Coumadin, g)
Levofloxacin (Levaquin)
Moxafloxacin (Avelox) Antineoplastics
Ofloxacin (Floxin) Cimetidine (Tagamet, g)
Sparfloxacin (Zagam) Cyclosporine (Sandimmune, Neoral)
Trovafloxacin (Trovan) NSAIDs
Probenecid (Benemid, g)
Theophylline
Caffeine
Ciprofloxacin
Acute ergotamine toxicity. Use cautiously
Steroid clearance may be decreased. Caution.
Avoid Clarithromycin with Prilosec
possible antagonism. Avoid static with cidal
Avoid all macrolides-risk of sudden death
AVOID CONCURRENT USE
.
Increased statin levels with possible muscle
toxicity. AVOID CONCURRENT USE
Increased theophylline levels (20-25%).
Decreased erythromycin levels may also
occur. AVOID CONCURRENT USE if
possible. SBE prophylaxis should not cause
problems.
Increased Detrol effects causing arrhythmias
Risk of bleeding disorders is increased in
anticoagulated patients. Consult MD.
Decreased metro. Levels. Increase dose.
Reduced absorption of metronidazole
Metronidazole levels may increase. Not sig.
Concurrent use may result in acute psychosis
or confusion.
Risk of disulfuram-type reaction. AVOID
CONCURRENT USE.
Increased lithium levels with possible toxicity.
Consult MD.
Eff. of phenytoin may be incr. Monitor closely.
Increased Quinidine levels. Monitor closely.
Metronidazole doubles Prograf levels
Reduced serum concentrations of tets.
Space administration by 1-2 hours.
Inhibition of tetracycline absorption.
Avoid concomitant administration.
Decreased absorption of tets. Space
use by 2-3h.Doxy always affected.
Slightly increased risk of ovulation.
Use additional method during cycle.
Metabolism of doxy increased. Monitor
response to doxycycline.
AVOID DOXYCYCLINE WITH IV
METHOTREXATE
Decreased serum levels and effect of
doxy. Monitor clinical response.
Phenytoin stimulates doxy metabolism.
Increase doxy dose or use other tet.
Colestipol binds tet in intestine. Do
not administer concomitantly.
Decreased absorption of tet. Space use
by 2-3 hours.
Tetracycline absorption is decreased.
Space use by 2-3 hours.
Decreased quinolone absorption. AVOID
CONCURRENT USE.
Increased risk of bleeding disorders. Monitor
INR.
Quinolone serum levels may be decreased.
Quinolone serum levels may be increased.
Cyclosporine renal toxicity may be enhanced.
Enhanced CNS stimulation
Quinolone serum level may be increased50%.
Increased theophylline toxicity possible with
Cipro and other. Consult MD
Increased caffeine effects are possible.
ANTIFUNGALS Anticoagulants (Coumadin) Increased risk of bleeding disorders in
Systemic Azole Agents (fluconazole, itraconazole, anticoagulated patient. Consult MD.
ketoconazole)
Benzodiazepines Alprazolam, triazolam are contraindicated with
itraconazole and ketoconazole. AVOID
Cyclosporine (Sandimune, Neoral) Increased cyclosporine levels. Can be used to
the patients advantage.
Rifampin Decreased levels of the antifungal. AVOID
. CONCURRENT USE.
Quinidine 30x increase in Quinidine. AVOID COMBO
"Statins" (Crestor,Lipitor, Mevacor,Zocor, etc.) Increased levels and SE of statins.
Terfenadine (not available in the U.S.) Increased terfenadine levels resulting in
serious cardiac arrhythmias. AVOID
CONCURRENT USE.
Tolterodine (Detrol, Detrol LA) Increased Detrol-causing arrhythmias.AVOID
Zolpidem (Ambien) Increased Ambien effect. Caution.
fluconazole (Diflucan) Cimetidine (Tagamet, g) Reduced fluconazole levels. AVOID
CONCURRENT USE.
Hydrochlorothiazide Increased fluconazole levels.
Losartan (Cozaar, Hyzaar) Increased Losartan hypotension effect
Oral Contraceptives Decreased estrogen levels. AVOID
CONCURRENT USE.
Phenytoin (Dilantin, g) Increased phenytoin levels. Monitor carefully.
Sulfonylureas Increased hypoglycemic effect. Monitor blood
glucose.
itraconazole (Sporonax) Digoxin Increased digoxin levels. AVOID
COMBINATION.
Increased gastric pH Reduced itraconazole levels
Isoniazid (INH) Reduced itraconazole levels
Losartan (Cozaar) Increased Losartan hypotension effect
Sulfonylureas Increased hypoglycemic effects. Monitor blood
glucose.
ketoconazole (Nizoral, g) Corticosteroids Possible increase in steroid levels.
Increased gastric pH Decreased ketoconazole levels. AVOID
CONCURRENT USE.
Isoniazid (INH) Decreased ketoconazole levels
Theophyllines Decreased theophylline levels. Consult with
MD.
NON-NARCOTIC ANALGESICS
NSAIDS
(including aspirin and COX-2s) Anticoagulants (apixaban, Increase risk of bleeding disorders in
dabigatran,rivaroxaban,warfarin) anticoagulated patient. Consult MD.
Antihypertensives (all but CCBs) Decreased antihypertensive effect. Monitor
(ACEI,B-blockers, diuretics) Blood Pressure.
Cimetidine (Tagamet, g) NSAID levels increased/decreased
Cyclosporine (Neoral, Sandimmune) Nephrotoxicity of both agents may be
increased. Avoid if possible.
Fluoroquinolones Increased CNS stimulation
Lithium Increased lithium levels. Use sulindac
Methotrexate (Rheumatrex, Mexate) Toxicity of methotrexate may be increased.
Monitor.
Phenytoin (Dilantin, g) Increased phenytoin levels
Probenecid (Benemid, g) Increased toxicity of NSAIDs possible.
Salicylates Decreased NSAID levels with increased GI
effects. AVOID CONCURRENT USE.
SSRIs Possible increased risk of bleeding but not
COX-2 SELECTIVE NSAID thought to be clinically significant
Celecoxib (Celebrex) 2C9 inhibitors (fluconazole) Increased celecoxib levels
Ibuprofen (Motrin, g) Digoxin
Ketorolac (Toradol,g) Salicylates
Sulindac DMSO
Sulindac Lithium
Acetaminophen only Barbiturates, Carbamazepine, Phenytoin,
Rifampin, Sulfinpyrazone
Cholestyramine (Questran, g)
. Ethanol
. .....
Tramadol (Ultram, Ultracet, g) Any drug that enhances serotonin activity(SSRI
antidepressants,triptans for acute migraine
Carbamazepine (Tegretol,g)
MAOIs (Marplan, Nardil, Parnate)
Quinidine
Ritonavir (Norvir)
NARCOTIC ANALGESICS
Opioid analgesics Alcohol, CNS depressants, local anesthetics,
antidepressants, antipsychotics, antihistamines,
cimetidine
Antimuscarinics and antidiarrheals (e.g. atropine),
antihypertensives (e.g. guanadrel)
Buprenorphine, nalbuphine, naltrexone
Codeine 2D6 Inhibitors, Amiodarone, Cimetidine,
Desipramine, Fluoxetine, Paroxetine,
Propafenone, Quinidine, Ritonavir
Meperidine (Demerol, g) MAOIs (Marplan, Nardil, Parnate, Furoxone)
selegiline (Eldepryl)
Protease inhibitors
Ritonavir (Norvir)
Propoxyphene (Darvon, Darvocet, g) Carbamazepine (Tegretol)
Protease inhibitors
LOCAL ANESTHETICS Alcohol,CNS depressants,opioids, antide-
pressants,antipsychotics, antihistamines
Antiarrhythmic drugs
Amides (e.g. lidocaine) Beta Blockers, cimetidine
Esters (e.g. procaine) Anticholinesterases (Neostigmine) Sulfonamides
VASOCONSTRICTORS (epinephrine,levo- Inhalation anesthetics (halothane)
nordefrin) Tricyclic antidepressants-high dose (amitriptyline,
desipramine, imipramine, nortriptyline, etc)
Beta-blockers (nonselective)
(e.g. propranolol, nadolol)
Phenothiazines (e.g. chlorpromazine)
Monoamine Oxidase Inhibitors (MAOIs)
Selegiline (Eldepryl,g)
COMT Inhibitors (Comtan, Tasmar)
Possible increase in digoxin levels.
Increased Ketorolac free drug conc.
Decreased sulindac effectiveness and severe
peripheral neuropathy. Avoid concurrent use.
Lithium levels remain constant or decrease.
The hepatotoxicity of APAP may be increased
by high dose or long term administration of
these drugs.
Decreased APAP absorption. Do not
administer within 2 hours of each other.
Increased hepatotoxicity of APAP with chronic
ethanol ingestion.
Possible serotonin syndrome. AVOID
CONCURRENT USE.
Decreased tramadol levels
MAOI toxicity enhanced
Tramadol increased/metabolite decreased
Increased Tramadol effect. AVOID COMBO.
Increased CNS and respiratory depression
may occur. Use cautiously.
Opioids increase the effects of these drugs.
Use cautiously.
These drugs block the analgesic effects of
opioids. Substitute with NSAIDs.
Inhibition of biotransformation of Codeine to
active analgesic form. Use different narcotic
on 2D6 Inhibitor patients.
Hypertension/hyperpyrexia or coma and
hypotension.AVOID CONCURRENT USE if
MAOI taken within 14 days.
Increased CNS/resp. depression- AVOID
Large increase in meperidine. AVOID
COMBO.
Carbamazepine metabolism is decreased.
Increased CNS/resp. depression- AVOID
Increased CNS and resp. depression may
occur. Use caution.
Increased cardiac depression.
Metabolism of lidocaine is reduced.
Use caution
Metabolism of esters reduced.
Inhibit sulfonamide action.
Increased chance of arrhythmia
Increased sympathomimetic effects possible.
Limit epi to 0.04mg with high dose TCA's.
Hypertensive and/or cardiac rx possible.
Limit epi to 0.04mg/2hr. visit.
Vasoconstrictor action inhibited,leading to
possible hypotensive responses. Use
cautiously.
Slight possibility of hypertensive rx.
Slight possibility of hypertensive rx.
Slight possibility of hypertensive rx.
AGENTS FOR PARENTERAL ANESTHESIA
Antihistamines
diphenhydramine (Benadryl)
hydroxyzine (Atarax, Vistaril)
Promethazine (Phenergan)
Barbiturates
methohexital (Brevital,g)
Benzodiazepines
diazepam (Valium,G)
midazolam (Versed,g)
Anticholinergics
CNS depressants (alcohol, narcotics)
CNS depressants (alcohol, narcotics)
Furosemide (Lasix, g)
Sulfisoxazole IV
CNS depressants (anticonvulsants, alcohol)
Cimetidine,OCs,INH,Ketoconazole,
Metoprolol, Omeprazole, Propoxyphene,
Propranolol,Valproic Acid
Digoxin
Calcium Channel Blockers or CCBs (diltiazem-
Cardizem, verapamil-Isoptin,Calan, Verelan)
CNS depressants (alcohol, barbs)
Increased dry mouth, tachycardia, urinary
retention. Monitor.
Enhanced duration and intensity of sedation.
Reduce dosages.
Additive CNS and resp. depression
Orthostatic hypotension
Sulfa competes with barb. for binding sites.
Smaller and more frequent barb. doses may have
to be given.
Oversedation so may use slower titration.
Decreased clearance of diazepam. Can avoid
with lorazepam.
Increased digoxin levels.
CCBs inhibit Cyp3A4 which prolongs the actions
of midazolam. Evaluate patient factors to
determine clinical significance.
Increased risk of underventilation or apnea. May
prolong the effect of midazolam.

Erythromycin Increased midazolam levels. Monitor.

Narcotics
fentanyl (Sublimaze,g)
meperidine (Demerol, G)
Miscellaneous
etomidate (Amidate)
ketamine (Ketalar,g)
Propofol (Diprivan, G)
Inhalation anesthetics Midazolam decreases MAC of halothane
Narcotics (morphine, meperidine, Increased hypnotic effect of midazolam. More
fentanyl) hypotension with Versed and Demerol.
Saquinavir (Fortovase) Increased midazolam levels. AVOID COMBO.
Thiopental After premed with Versed, decrease dose of
thiopental for induction by 15%
Barbiturate anesthetics Additive CNS and resp. depression.
Chlorpromazine (Thorazine, g) Increased toxicity of both agents.
Cimetidine (Tagamet, g) CNS toxicity case reports only. (confusion, apnea,
seizures)
Diazepam With high dose fentanyl gives CV depression.
Droperidol (Inapsine) Hypotension and decreased pulmonary arterial
pressure.
Nitrous Oxide With high dose fentanyl may cause CV depress.
Ritonavir (Norvir) Increased fentanyl levels with Norvir
Barbiturate anesthetics Additive CNS and resp. depression
Chlorpromazine (Thorazine, g) Increased toxicity of both agents.
Cimetidine (Tagamet, g) CNS toxicity as with fentanyl.
MAOIs and furazolidone (Furoxone) Meperidine has predictable and sometimes fatal
reactions with use within 14 days. TypeI
:coma,resp dep,cyanosis,low BP
Type2:seizures,hyperpyrexia,hypertension,tachy-
cardia. AVOID CONCURRENT USE!!!!!
Phenytoin (Dilantin, g) Decrease meperidine effects by increased hepatic
metabolism
Verapamil Possibility of prolonged anesthesia
Barbiturates Prolonged recovery time.
Halothane Halothane blocks the CV stimulate effect
of ketamine.Closely monitor cardiac function.
Thyroid Hormone May produce hypertension/tachycardia
Tubocurarine and nondepolarizing muscle Ketamine may increase neuromuscular effects
relaxants and result in prolonged resp. depression.
CNS depressants (sedative/hypnotic, inhalation Increase CNS depression of propofol. Premed
anesthetics, narcotics) with narcotics may lead to more pronounced
decrease in systolic, diastolic, and mean arterial
pressures and cardiac output.
DRUG-INDUCED QT INTERVAL PROLONGATION RECOGNITION AND AVOIDANCE

What risk factors for drug-induced QT prolongation and TdP are present in the patient? Are any risk
factors modifiable?
As mentioned in Part I and in a scientific statement by the American College of Cardiology (ACC) and
American Heart Association (AHA), there are numerous known risk factors for drug-induced TdP
including:1,2

A QTc interval >500 msec or an increase in QTc interval by >60 msec compared to baseline
Genetic predisposition ion channel mutations leading to congenital QT prolongation
Heart disease including heart failure and myocardial infarction
Bradycardia
Female gender
Advanced age
Concomitant administration of >1 drug known to cause QT prolongation or TdP*
Hypokalemia or hypomagnesemia*
Rapid intravenous (IV) infusion of a drug known to cause QT prolongation or TdP*
Drug interactions or organ dysfunction (hepatic, renal) that cause elevated plasma drug levels*
History of drug-induced TdP

*Modifiable risk factors