A member of DOCS Education writes:
A new patient presented last week and expressed an interest in sedation dentistry. He has just completed 14 weeks of a 48-week course of chemotherapy as part of treatment for hepatitis C. This is the man’s third round of chemo in recent years (the first two rounds were not successful).
The medications the patient takes include PEGASYSâ„¢ (peginterferon alfa-2a) and 600 mg ribavirin. New regulations in the state of Maryland limit me to an anxiolysis protocol. Are there indications or contraindications for this patient? If anxiolysis is acceptable, what protocol would you use? Would I be asking for trouble if I added nitrous oxide/oxygen to the mix?
Dr. Leslie Fang, a member of the DOCS Education faculty, responds:
The medications the patient is taking do not present the problem. The issue here is the patient's ability to metabolize medication. You should examine recent liver function tests on this patient before proceeding. Of particular concern are the ALT (SGPT) and AST (SGOT) results. Both should be less than 200 units/L. Otherwise outpatient sedation is not recommended.
If the liver function tests fall within acceptable ranges I would recommend a single-dose protocol appropriate for the anticipated length of the appointment. (For example, single-dose protocol number 1 for up to one hour of treatment, etc.) While the argument can be made that that a lorazepam protocol is more forgiving of the liver, if the patient’s liver function is adequate conservative doses of any DOCS Education sedation medications should be fine.
Dr. Anthony Feck, Dean of DOCS Education faculty responds:
I would want to be sure that the INR (international normalized ratio) is totally normal, in order to assess the synthetic capabilities of the liver.
I would also need to know the CBC to ensure that the platelet count and the hemoglobin are normal (both may be suppressed due to disease and treatment with peg-slated interferon).
Lorazepam may be safer than triazolam in this instance because of the sensitivity of CYP3A4 to liver disease.
