A DOCS Education member writes:
My patient has been diagnosed with arthritis and osteoporosis. Although she has not reported any psychiatric problems, the list of her prescribed medications suggests treatment for these types of disorders. The woman is 68 years old.
The patient suffers from severe dental decay due to drug-induced xerostomia accompanied by the chronic use of sugared mints. Her condition necessitates the use of multiple appointments. Here is a list of the medications she is currently taking: Actonel,™ citalopram, cyclobenzaprine, hydrochlorothiazide, meloxicam, methotrexate, Nexium,™ nystatin and trazodone. Of course I performed a Lexi-Comp interaction analysis. I propose using an incremental triazolam dosage without diazepam the night before the appointment. Could you advise?
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
If the Lexi-Comp analysis revealed only the existence of C interactions I wouldn’t advise changing the protocol. However, you should consider adjusting the dosages.
This is an example of a case where any of the DOCS Education sedation protocols can be used. That’s because none of the drug interactions is more severe than C. Also, the age of the patient doesn’t demand you rule out a protocol.
As you have already discussed, I would not have this particular patient take diazepam the night before. That’s because she’s already using three or more CNS depressants. Because she is over 65 you should cut the loading dose of triazolam by 50 percent to 0.125 mg.
The patient’s medications indicate she is being treated osteoporosis, depression, anxiety, muscle pain and tension, hypervolemia (probably hypertension), GERD, a yeast infection and arthritis. She should continue to take the drugs prescribed to address these as usual. If well-controlled none of these conditions should affect sedation. However, medication used to treat them can complicate sedation in the following ways:
Actonel is an oral bisphosphonate. Increased risk of osteonecrosis of the jaw now exists should oral surgery take place. The patient needs to be carefully informed about this possibility and you need to acquire consent. Due to the fact the patient is taking multiple CNS depressants, she is likely to hyporespond. Finally, the diuretic may cause the patient to urinate more frequently during the sedation appointment.
