Pharmacology reference by Michael L. Iczkovitz, D. D. S



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Synthetic, Methadone Group+

Propoxyphene and Aspirin (Darvon Compound-65 Puvules)

Effects same as individual components.

Pentazocine (Talwin, Talwin NX)

Action: Binds to Kappa and Delta opiate receptors (agonist), decreasing pain. Antagonist to Mu opiate receptor.

Use: Moderate to severe pain, preoperative sedative and supplement to surgical anesthesia.

Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, headache and tinnitus. Pregnancy ok, except near term (neonatal respiratory depression), lactation no.

  • Synthetic, Benzomorphan Group

Pentazocine (Talwin, Talwin NX) (Continued)

Medical Considerations: >10%; Euphoria, drowsiness, nausea, vomiting and weakness.

Medical Considerations: 1-10%; Hypotension, restlessness, nightmares, skin rash, ureteral spasm, blurred vision and dyspnea.

Medical Considerations: <1%; Palpitations, bradycardia, peripheral vasodilatation, insomnia, CNS depression, sedation, hallucinations, confusion, disorientation, seizures if history, increased intracranial pressure, pruritis, antidiuretic hormone release, GI irritation, constipation, biliary spasm, urinary tract spasm, miosis and histamine release.

Dental Drug Interactions: Increased effect of CNS depressants. May potentiate or reduce analgesic effect of opiate. Can cause withdrawal in narcotic addicts. Increased effects of anticholinergics.

Medical Drug Interactions: Don’t give with MAO inhibitors. Can be lethal with antihistamine tripelennamine (PBZ, PBZ-SR).

Medical Drug Interactions: Increased effect with phenothiazines.

Precautions: Pregnancy category B (D long term or high dose), lactation, severe renal and hepatic disease and Addison’s disease. Prostatic hypertrophy and respiratory

depression. NX means naloxone added decreases addictive potential, euphoria.

Increases withdrawal risk.

INTERACTION BETWEEN SPECIFIC DISEASES AND DENTAL PHARMACOLOGY




  • Ischemic Heart Disease

Angina pectoris: Don’t give anticholinergics (Probanthine), increases cardiac rate

and oxygen demand, arrhythmias possible.

Previous myocardial infarction (MI): Don’t give aspirin or other NSAIDs for post

-op pain. If surgery and MD oks may want to be off aspirin 7-10

days pre-op.


  • Asthma

Attacks stimulated by aspirin, NSAIDs, barbiturates,

Narcotics and cold air.


If taking theophylline no macrolide antibiotics (Erythromycin, Azithromycin or

Clarithromycin) or Ciprofloxacin, may cause theophylline toxicity.


Antihistamines should be used with caution due to drying effects.
Local anesthetics with epinephrine or levonordefrin contain sulfite preservatives,

may cause asthma attack.


Oral candidiasis possible with steroid inhalers.

If taking oral corticosteroids for one week in last six months may be adrenal

suppressed. If stressful procedure Adrenal Supplementation Regimen is to double

normal steroid dose day of procedure and first postoperative day.


Stress may cause asthma attack. Premedication with oral diazepam ok. Nitrous

Oxide during procedure is excellent, not a respiratory depressant and doesn’t

irritate tracheobronchial tree.
Have patient bring asthma medications to appointment. Ask if any asthma

symptoms prior to dental treatment.




  • COPD

Avoid nitrous oxide, high oxygen flow may depress respiratory drive. Also nitrous

oxide accumulates in enlarged air spaces in lung with emphysema. If must use



oxygen use at low 2-4 liter flow rate.
Anticholinergics and antihistamines cause drying which increases mucous tenacity,

so don’t use. Narcotics and barbiturates can cause respiratory depression.


Watch for concomitant CAD and hypertension. If taking oral steroids may need to

follow Adrenal Supplementation Regimen. No office GA or IV sedation.





  • COPD (continued)

If taking theophylline no macrolide antibiotics (Erythromycin, Azithromycin or

Clarithromycin) or Ciprofloxacin, may cause theophylline toxicity.




  • Diabetes Mellitus

NPO rules for general anesthesia. Stop medications evening before surgery. Longer

acting oral agents must be stopped sooner. Glyburide (Diabeta, Micronase) stop 24

hours pre-op, Chlorpropamide (Diabinese) 36 hours and Metformin (Glucophage)

48 hours.




  • Bleeding Disorders, GI Disease

Avoid aspirin, aspirin compounds and NSAIDs. Use acetaminophen and codeine.


  • Kidney Failure

Heparin given during dialysis can cause bleeding problems. Perform dental surgical

procedures 4-30 hours after dialysis and 24-48 hours prior to next dialysis.


Avoid nephrotoxic drugs: NSAIDs, aminoglycosides, acyclovir, radiographic

contrast media. Meperidine and propoxyphene converted to renal toxic metabolites,

don’t use. Penicillin G and magnesium citrate have excessive electrolytes, don’t use.
Reduce dose of ketoconazole. Increase interval between doses with aspirin,

Acetaminophen, penicillin V, cephalexin and tetracycline.


No problems using the following drugs: Codeine, erythromycin, valium,

clindamycin and metronidazole (Flagyl).




  • Liver Failure

Dental drugs metabolized primarily by the liver: Local anesthetics; Lidocaine

(Xylocaine), Mepivacine (Carbocaine), Prilocaine (Citanest) and Bupivacaine

(Marcaine). Analgesics; Aspirin, Acetaminophen, Codeine, Meperidine (Demerol)

Ibuprofen (Motrin) and Propoxyphene (Darvon). Sedatives; Diazepam (Valium)

and Barbiturates. Antifungals; Ketoconazole. Antibiotics: Ampicillin, Penicillin,

Erythromycin, Clindamycin, Metronidazole and Tetracycline.


Most drugs used in dentistry metabolized by liver. Unless severe hepatic

Dysfunction can use drugs in limited quantity (Three cartridges 2% lidocaine is

108 mg, ok).


  • Immunocompromised

HIV+: No antibiotic prophylaxis necessary.

AIDS: Antibiotic prophylaxis.



  • Immunocompromised (continued)

HIV Drugs:

Protease inhibitors ritonavir (Norvir), indinavir (Crixivan), Saquinavir (Invirase)

and benzodiazepines increase benzodiazepine levels. Adjust benzodiazepine dose

or don’t use. Azole antifungals, ketoconazole, clarithromycin mixed with protease



inhibitors can be cardiotoxic with fatal arrhythmias. Produces large increases in

concentrations of meperidine and propoxyphene, don’t use with protease inhibitors.
Metronidazole and liquid ritonavir (contains alcohol) get disulfarim (Antabuse)

like reaction.


Some antihistamines) mixed with protease inhibitors can be cardiotoxic with fatal

arrhythmias.
Organ Transplant Drugs:
Follow Adrenal Supplementation Regimen if on steroids and procedure is

stressful.


Cyclosporin is hepatotoxic, neurotoxic and causes hypertension and gingival

hyperplasia.


Azathioprine (Imuran) causes hepatotoxicity, thrombocytopenia and leukopenia.
Mycophenolate (CellCept) causes leukopenia. Don’t use NSAIDs,

aminoglycosides and acyclovir with mycophenolate as causes nephrotoxicity.

Tarcolimus, a potent macrolide immunosuppressant, is nephrotoxic, neurotoxic

and diabetogenic. Macrolide antibiotics, azole antifungals and corticosteroids

Increase tarcolimus concentration.


Antihistamines terfenadine (Seldane) and astemizole (Hismanal) cause cardiac

arrhythmias when used with tacrolimus and cyclosporine.


If WBC < 2,000 need antibiotic prophylaxis.


  • Pregnancy

Anesthesia

No office sedation or general anesthetics. No nitrous oxide, chronic

exposure increases spontaneous abortions. Local anesthesia fine.

Acetaminophen drug of choice. Therapeutic short-term meperidine (Demerol)

And fentanyl fine. Oxy/hydrocodone not bad. Propoxyphene not good.

Codeine causes congenital anomalies.




  • Pregnancy

Analgesia (continued)

Aspirin causes anemia, antepartum or postpartum hemorrhage and intracranial

fetal hemorrhage. Pentazocine (Talwin) no congenital defects, but may cause

severe neonatal respiratory depression, avoid giving near term. Avoid NSAIDs

during third trimester and new research suggests throughout pregnancy.
Antibiotics

Penicillins, cephalosporins, erythromycin and clindamyacin not teratogenic.

Don’t use aminoglycosides, tetracycline, metronidazole and sulfonamides.
Corticosteroids

Increases risk of maternal infection and neonatal sepsis, don’t use.


Anticholinergics

Don’t use Pro-Banthine.


Muscle Relaxants

Cyclobenzaprine (Flexeril) one of only possible drugs to use.




  • Lactation

Amount of drug in breast milk usually not more than 1-2% maternal dose.

Don’t use aspirin, tetracycline, barbiturates or benzodiazepines. No consensus

on NSAIDs, oxy/hydrocodone, pentazocine and muscle relaxants, so should

probably avoid. All other drugs commonly used in dentistry ok, codeine ok,

nitrous oxide ok.
Breast feeding instructions. Instruct mother to take drugs just after breast

Feeding and avoid nursing for four or more hours after taking drugs. Pre-op

Pumping and storing milk good.


  • Hypothyroid

Untreated very sensitive to sedatives and opiods, use non-narcotic analgesics.

Well controlled, no treatment problems.




If taking steroids and stressful procedure follow Adrenal Supplementation

Regimen. Steroids also delay healing, cause hypertension, more susceptible

to infection.



  • Sickle Cell Anemia

Chronic anemia, increased severity of dentoalveolar infections, osteomyelitis,

  • Sickle Cell Anemia (continued)

poor healing.
Increased anesthesia risk so not good candidates for office IV.

sedation or GA. Local anesthesia without vasoconstrictor ok. If

surgery vasoconstrictor ok, aspirate well. Nitrous oxide controversial. If

use must have at least 50% oxygen, watch for diffusion hypoxia.


High dose salicylates cause acidosis. Acetaminophen and small doses of

Codeine drug of choice for pain control.




  • G-6-PD Deficiency

G-6-PD MED, drugs usually trigger mostly sulfonamides, aspirin, phenacetin

and chloramphenicol. Also penicillin, streptomycin and isoniazid.




  • Substance Abuse

Alcohol

CNS depressant, increases effects of narcotics, benzodiazepines and

barbiturates.

Chronic users may require greater anesthetic dosages.


Avoid narcotics as often multiple addictions.
Therapeutic doses of acetaminophen mixed with alcohol may cause liver

failure.

Opiods

Medical problems include liver disease and infectious diseases (HIV,

infectious hepatitis and endocarditis). Intravenous drug use history, consider

antibiotic prophylaxis.

High tolerance to pain medication, difficult IV access, behavior problems

and higher dose requirements of anesthetic agents. If on methadone, take

pre-op. Droperidol good for dissociative effect.

Avoid narcotic antagonists, may cause withdrawal (Talwin NX). Can

develop profound hypotension during IV sedation and GA.
Heroin causes xerostomia, cervical caries.
Management principals: Agree prior to procedure on type and time on

narcotics. If cured addict (any substance) avoid narcotics, NSAIDs

preferred.



  • Seizure Disorder

Phenytoin, carbemazepine and valpoic acid may cause leukopenia and

thrombocytopenia. Don’t use NSAIDs with these medications. No

propoxyphene or erythromycin with carbemazepine.


  • Stroke

Coumadin monitor by PT or INR.
Aspirin or antiplatelet drugs (dipyridamole) monitor by bleeding time: >10

minutes, slightly increased bleeding risk, >20 minutes, significant bleeding risk.




  • Arthritis

Aspirin and NSAIDs watch for bleeding.

If rheumatoid arthritis may be taking gold salts, penicillamine,

immunosuppressives or sulfasalazine causing stomatitis.
If stomatitis with bleeding and ulceration watch for blood dyscrasias; anemia,

agranulocytosis or thrombocytopenia.


If steroids may need supplementation.
If joint prosthesis antibiotic prophylaxis.



  • Allergies and Congestion

Antihistamines have additive CNS depression with CNS depressants and

alcohol. Increased anticholinergic effects with anticholinergics and other

antihistamines.

Don’t use ketoconazole or erythromycin with antihistamines, can result in liver

damage and cardiac arrhythmias with possible fatalities.

No arrhythmias reported with loratadine (Claritan), fexofenadine (Allegra),

clemastine (Tavist), diphenhydramine (Benadryl), meclizine (Antivert).

Reported problems with cetirizine (Zyrtec).


Decongestants, don’t use local anesthetic with vasoconstrictor, can cause

pressor response. Sedation with CNS depressants and Alcohol. Arrhythmias

with inhalation anesthetics. Medications include Pseudoephedrine (Sudafed,

Actifed Tabs, Afrin Tabs, Triaminic), Oxymetazoline (Afrin) and Ephedrine.


VASOCONSTRICTORS


  • Cardiovascular Disease

Healthy adult can receive up to 0.2 mg of epinephrine within 15 minutes. Each c.c.

of 1:100,000 epinephrine contains 0.01 mg. Carpule is 1.8cc, so contains 0.018 mg.

No more than 10 carpules in 15 minutes.
Vasoconstrictor Precautions: With cardiovascular disease limit to 0.04 mg

epinephrine or 0.2 mg levonordefrin in 15 minutes, no more than 2 carpules.


With cardiovascular disease don’t use gingival retraction cord containing

epinephrine. Don’t use 1:50,000 epinephrine. Avoid intraligamental and

intraboney injections with vasoconstrictor local anesthetics.
Avoid vasoconstrictors if taking noncardioselective beta-blockers: Carteolol

(Cartrol, Ocupress), Carvedilol (Coreg), Nadolol (Corgard), Penbutolol (Levatol),

Pindolol (Visken), Propranolol (Inderal) and Timolol (Blocadren). Can use

1:100,000 epinephrine if monitor pre and post injection vital signs, give ½ carpule,

wait 5 minutes, if no change can repeat process. Can use levonordefrin in same

manner.
If patient taking Digoxin (Lanoxin) check with physician prior to using

vasoconstrictor.



  • Arrhythmia

Same Vasoconstrictor Precautions except if serious arrhythmia don’t use

vasoconstrictor in local anesthetic.




  • Psychiatric Disorders

Potential for hypertensive crisis, myocardial infarction mixing vasoconstrictors

with neuroleptic and heterocyclic medications.


Neuroleptic agents (Antipsychotic drugs) are Chlorpromazine (Thorazine),

Fluphenazine (Permitil), Trifluoperazine (Stelazine), Mesoridazine (Serentil),

Haloperidol (Haldol), Molindone (Moban). If patient is not acutely hypotensive

due to these medications and can avoid intravascular injections, can use

vasoconstrictors in normal dosages. Hypotensive reaction can result from alpha

adrenergic blockade and increase epinephrine results in only beta-2 vasodilative

effects.
Heterocyclics (TCAs) are Amitriptyline (Elavil), Imipramine (Tofranil),

Amoxapine (Asendin), Maprotiline (Ludiomil). If use 1:100,000 epinephrine give

no more than 1/3 maximum dose. Additional dosages after 30 minutes. Don’t use

levonordefrin (Carbocaine with Neocobefrin). Some gingival retraction cords

contain large amounts of epinephrine, don’t use.


  • Psychiatric Disorders (continued)

MAO inhibitors are Phenelzine (Nardil), Isocarboxazid (Marplan) and

Tranylcypromine (Parnate). Use local anesthesia without vasoconstrictor

whenever possible. If must use limit to two carpules 1:100,000 epinephrine

within 15 minutes, aspirate.





  • Substance Abuse

Stimulants, Cocaine and Methamphetamine

Local anesthesia with vasoconstrictor can cause life threatening arrhythmias and

hypertensive crisis. General anesthetics can be dangerous as are mixing with

psychotropic drugs.




  • Miscellaneous Vasoconstrictor Interactions

Don’t use vasoconstrictor if patient has:

1. Pheochromocytoma

2. Hyperthyroid

3. Significant risk with phenylephrine (OTC cold medication)

4. Phentermine (Fastin)

5. Ritalin if patient is hypertensive

Use with caution if:

1. General anesthetic agents; Halothane (Fluothane), Enflurane (Etharane),

Isoflurane (Forane) and Thiopental (Pentothal). Check with anesthesiologist

to see if can use and in what amounts.

2. Guanethidine (Ismelin) and Guanadrel (Hylorel) antihypertensives follow TCA

precautions.



Dental Drug Interactions


  • Antibiotics

Penicillin Derivatives: Tetracyclines, erythromycin and clindamycin decrease

effectiveness. Acts synergistically with aminoglycosides. Probenecid will increase

blood levels.

Penicillin, Amoxicillin, Ampicillin, (Augmentin), and (Unasyn)
Macrolide: Decreases action of clindamycin, penicillins and oral contraceptives.

Increases effects of oral anticoagulants and benzodiazepines. Medical; increases

effects of alfentanil, carbamazepine, theophylline, felodipine, triazolam and

ergotamine. Contraindicated with azole antifungals, statins, theophylline,



(Erythromycin and Clarithromycin).

Erythromycin, Clarithromycin (Biaxin) and Azithromycin (Zithromax)


Lincomycin Derivatives: Decreases activity of erythromycin, increases activity of

nondepolarizing muscle relaxants and hydrocarbon inhalation anesthetics.



Clindamyacin (Cleocin)
Cephalosporins: Decreased bactericidal effects with tetracyclines and erythromycin.

May reduce effectiveness of oral contraceptives. Probenecid decreases elimination.

Cephalexin (Keflex, Keftab) 1st generation

Cefadroxil (Duricef) 1st generation

Cefprozil (Cefzil) 2nd generation



Cefuroxime (Ceftin) 2nd generation

Cefaclor (Ceclor) 2nd generation

Loracarbef (Lorabid) 2nd generation

Cefpodoxime (Vantin) 2nd generation

Cefixime (Suprax) 3rd generation
Tetracycline Derivatives: Decreases effect of penicillin, cephalosporin, oral

contraceptives. Increases oral anticoagulant effect. Absorption reduced by dairy

products, calcium, magnesium or aluminum containing antacids, iron, zinc, and

cimetidine. Outdated drug can cause nephropathy. If give with Methoxyflurane



anesthesia can cause fatal nephrotoxicity.

Tetracycline (Achromycin, Sumycin, Tetracyn)



Minocycline (Minocin)

Doxycycline (Vibramycin)

Tetracycline Periodontal Fibers (Actisite)



  • Antifungals

Fluconazole (Diflucan)

Increases coumadin and benzodiazepine activity. Rifampin decreases fluconazole

activity. Arrhythmias possible with antihistamines.
Metronidazole (Flagyl)

None with Disulfiram (Antabuse), causes psychosis.
Clotrimazole (Mycelex Troche)

Increases activity of cyclosporines and sulfonylureas.




  • Antivirals

Acyclovir (Zovirax)

Increased CNS side effects with zidovudine (AIDS drug) and probenecid.




  • Non-Narcotic Analgesic

Non-Steroidal Anti-inflammatory Drugs (NSAIDs)

Salicylate NSAIDs

Increases bleeding risk with oral anticoagulants. Avoid corticosteroids and

Acetaminophen. Can cause toxicity of Diamox (CNS) and methotrexate (hepatic).

Increased GI bleeding and complaints with alcohol. Increased risk bleeding valproic

acid, dipyridamole. Increased toxicity lithium and zidovudine. Decreased effects

of probenecid and sulfinpyrazone.



Acetylsalicylic Acid (Aspirin, Anacin, Bayer, Bufferin, Ecotrin,

Empirin)
Propionic Acid Derivative NSAIDs

Same as salicylates. Nephrotoxic with acetaminophen. Increased photosensitivity

with tetracycline. Increased toxicity diuretics. Not with methotrexate.

Ketoprofen (Orudis, Oruvail)

Oxaprozin (Daypro)

Naproxen (Aleve, Anaprox, Naprosyn)



Ibuprofen (Advil, Motrin, Midol, Nuprin, Rufen)
Acetic Acid Derivative NSAIDs

Same as other NSAIDs plus decreases antihypertensive effects beta-blockers,

hydralazine and captopril. Increases serum potassium of potassium sparing

Diuretics. Nephrotoxic with cyclosporine. Increases toxicity of digoxin and

Aminoglycosides. Probenecid increases this medications serum concentration. Not

with lithium or methotrexate.

Acetic Acid Derivative NSAIDs (continued)

Indomethacin (Indocin)

Diclofenac (Cataflam, Voltaren)

Nabumetone (Relafen)

Etodolac (Lodine)



Sulindac (Clinoril)
Other NSAIDs

Diflunisal (Dolobid)

Decreased effect with antacids. Increased toxicity with digoxin, methotrexate,

anticoagulants, phenytoin and sulfonylureas. Increased toxicity with sulfonamides,

indomethacin, hydrochlorothiazide, lithium and acetaminophen.
Piroxicam (Feldene)

GI ulcer, bleeding with aspirin, alcohol and corticosteroids. Nephrotoxicity with

Acetaminophen (prolonged use, high dose). Decreased action salicylates. Risk of

increased effects oral anticoagulants, oral antidiabetics, lithium and methotrexate.

Decreased antihypertensive effects of diuretics, B-adrenergic blockers and ACE

inhibitors. Decreased effect with aspirin, antacids and cholestyramine.


Mefenamic Acid (Ponstel)

Increases effects of oral anticoagulants. Decreased effect with aspirin. None with



corticosteroids, methotrexate and lithium.
Cox-2 Inhibitors

Don’t use with aspirin, increased activity of oral anticoagulants. Other reactions

Same as other NSAIDs.

Celecoxib (Celebrex)

Rofecoxib (Vioxx)
Para-aminophenol Derivates

Barbiturates liver toxicity of high doses of acetaminophen. Therapeutic doses with

alcohol may cause severe hepatic toxicity. Nephrotoxicity with long-term

consumption especially if combined with NSAIDs. Buffered acetaminophen

decreases tetracycline absorption. Cholestyramine reduces effect. Hepatic toxicity

possible with INH and Dilantin.



Acetaminophen (Tylenol, Aspirin Free Anacin, Tempra)


  • Non-Narcotic Analgesic?

Tramadol (Ultram)
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