A DOCS Education member writes:
My 66-year-old patient takes propranolol and levothyroxine. While no contraindications appear between these drugs and triazolam, I'd welcome additional guidance about the situation.
The woman's primary care physician advises 2 mg amoxicillin one hour before treatment due to mitral valve prolapse. The doctor also suggests propranolol later in the day (but no thyroid medication). The woman will take 5 mg Valiumâ„¢ the night before.
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
Two concerns strike me immediately. First is the elderly age of the patient. The second is the interaction between the nonselective beta blocker propranolol and the vasoconstrictor epinephrine in the local anesthetic.
Address the first issue, elderly age, by cutting in half the dose of diazepam and the loading dose of triazolam.
In the office, dose low and slow to effect.
As far as the vasoconstrictor goes, use local anesthetic with vasoconstrictor judiciously and slowly, carefully monitoring your patient.
I confess I'm puzzled by the instructions of the primary care physician. Withholding patient medications is generally open for debate. In any case I would go ahead and follow those instructions anyway.
My suggestion is different regarding the antibiotic prophylaxis. That flies in the face of current recommendations. Advise the primary care physician of that fact. They may still hold to the stance. In that case insist they write the prescription for the amoxicillin and document it in the patient's record.
