A 50-year-old woman takes a host of medications to treat the diagnoses of lupus, rheumatoid arthritis and ulcerative colitis. She also reports allergies to latex, alcohol, epinephrine and lidocaine. While these combinations pose considerations in regard to successful sedation, is allergic reaction one of them? A DOCS Education member writes:
The patient is a woman with several chronic medical conditions. She is 50 years old. Her blood pressure measured 128/77 with a pulse of 58 bpm. Among her diagnoses are lupus, rheumatoid arthritis, ulcerative colitis and rosacea.
As might be imagined the patient’s list of medications is quite extensive. Because of her history of migraines she takes verapamil, Inderal™ and Pamerol™.
Part of her treatment for ulcerative colitis includes Asacol™.
She receives folic acid, methotrexate and leucovorin on account of the lupus/RA. In addition, supplements she lists are glucosamine, fish oil and vitamin D.
The woman also reports a fairly long list of allergies: latex, epinephrine, morphine, lidocaine, Biaxin™, alcohol and adhesives.
We believe ourselves restricted regarding which sedatives and pain relievers are appropriate. Due to the appearance of interaction rating D, we planned to use lorazepam instead of diazepam—at a lower dose—the evening before the appointment.
The day of treatment we planned to supplement lorazepam and hydroxyzine with nitrous oxide if necessary. We also intend to provide the patient Tylenol Extra Strength™ if additional pain relief is warranted. Is this an adequate schedule or do you have other recommendations?
Dr. Leslie Fang, a member of the DOCS Education faculty, responds:
You’ve analyzed this case beautifully and I want to commend you. Let me add other thoughts.
Since methotrexate is a hepatotoxic you should explore further to be assured that liver function and INR (International Normalized Ratio) are not issues. Be certain as well that CBC is normal on methotrexate.
In view of liver concerns, limit this patient’s use of acetaminophen to 1500 mg per day.
Finally, it’s important to find out more about her allergy to epi and lidocaine. True caine allergy is extremely rare.
Dr. Jerome Wellbrock, responds:
Thanks for writing. I agree with Dr. Fang that you have analyzed this case very thoroughly. Was this patient told they had an allergy to epinephrine or did they merely misinterpret the typical adrenaline rush that follows the intravascular injection during administration of local anesthetic? (Several of my patients have made the same mistake.)
I ask this question because epinephrine is a substance that is naturally produced by the human body. For that reason a true allergy is all but impossible.
Lidocaine and mepivacaine are both considered of the amide group of local anesthetics. While a local anesthetic allergy is rare in the amide group it is much more common in the ester group.
I would skip the meds the night before and expect to spend more time in the office waiting while the lorazepam/hydroxyzine to take effect.
