A DOCS Education member writes: A 30-year-old man came to me today for a consultation for oral conscious sedation. He is on Xanax® 1mg q6h prn, Seroquel® 300 mg at night, Cymbalta® 60 mg qd at night, and Adderall® 60 mg tid.
His treating physician says the patient is suffering from bipolar disorder, ADHD, and panic attacks. The MD says the patient is under "good control," is not schizophrenic and is not suffering from any other psychosis.
There are a number of issues here including the manic depressive illness, the multiple CNS depressants, the Adderall® which is a stimulant and the probable need to limit epi with the Seroquel® and Adderall®. Also Seroquel® prolongs the QT interval as we learned a few weeks ago. Lexicomp shows multiple class C interactions.
Do you recommend treating him? This promises to be a potentially difficult sedation. He requires several extractions and a few crowns. He may eventually have some implants and additional crowns.
Dr. Leslie Fang, DOCS Education Faculty responds:
Dissecting the case out:
- Bipolar disease: always a concern because of the cycling nature of this disease. However, this guy is probably extremely low-grade bipolar, judging from his medications. He is only on Cymbalta® and Seroquel®. Cymbalta® is an anti-depressant and Seroquel® is a fairly low-key mood stabilizer. I am not too concerned about this aspect of his disease. Verification of my assessments below would reassure me even more:
- I bet he has never been hospitalized either for severe depression or mania
- I bet he does not have frequent or high highs (manic episodes)
- Not infrequently, patients with ADHD winds up with some behaviors that are hyper and can be misinterpreted as hypomania
- Panic attack: on Xanax® 16h prn
- ADHD: on Adderall® in hefty doses
The patient can be treated with all of the understanding of the drug-drug interactions:
- Xanax® and Seroquel® as CNS depressants
- Cymbalta® having a minor CNS depressive effect
- Adderall® as a stimulant.
It is clear that this is another instance where you would have no clear way of predicting his response to sedation and you should go low and go slow.
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
I would treat this patient. You and Les have identified all the issues. Dosing low and slow to effect ("titrating" is reserved for a more immediate response than we get with OCS) should enable you to take this patient to a level of comfort they need to receive their dental care without the complications that can occur in the presence of CNS depressants they are already taking.
While we're on the subject, my personal experience has shown that it is actually rare that a patient on CNS depressants acts as a hyper-responder. More often than not, they hypo-respond. It is most likely that the anxiety that prompted the CNS depressant, and/or the tolerance they have developed make the low and slow approach unnecessary. Still, it is the right thing to do given the undesirable consequences of oversedation.
As Dr. Fang pointed out, it is impossible to determine pre-operatively how the stimulant Adderall® will affect the sedation. In the "hyperactive" (I know, politically incorrect, but I'm using the term for my purpose) patient, it has a calming effect. I would prefer he take the Xanax® the night before and stay away from the diazepam.
The bipolar disorder can add an element of uncertainty to the process as the patient's elevated or depressed mood at the time of the sedation can affect the dose amounts and time of induction.
