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What is the category of Nitroglycerin SL and Isosorbide dinitrate?
Nitrates
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What is the category of Amiodarone, Digoxin, Flecainide, and Sotalol?
Antiarrhythmics
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What is the category of Atorvastatin, Ezetimibe, Gemfibrozil, Lovastatin, Nicotinic acid, Pravastatin, Rosuvastatin, Simvastatin, and Simvastatin/Ezetimibe (Vytorin)?
Lipid lowering
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What is the category of Aspirin, Clopidogrel, and Warfarin?
Blood Thinners
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What are the common dentally significant adverse effects of Antiarrhythmics?
*amiodarone, digoxin, flecainide, sotalol*
- amiodarone skin discoloration
- all agents-bradycardia
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What are the common dentally significant adverse effects of Lipid lowering drugs?
*atorvastatin, ezetimibe, gemfibrozil, lovastatin, Nicotinic acid, pravastatin, rosuvastatin,
simvastatin, Simvastatin/ezetimibe (Vytorin)*
- Statins-HA
- GI
- abnormal taste
- muscle pain/weakness
- Increased gag reflex (all lipid drugs can cause this effect)
- Nicotinic Acid-“hot flashes”
- Ezetimibe-not used much now due to possible pancreatitis risk
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What are the common dentally significant adverse effects of Blood Thinners?
*aspirin, clopidogrel, warfarin*
Most worrisome adverse effect is excessive bleeding and this is potentially most significant with warfarin therapy
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What are the common dentally significant adverse effects of Nitrates?
*nitroglycerin SL, isosorbide dinitrate*
- dizziness
- orthostatic hypotension
- flushing
- HA
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What are the major dental tx impacts of Nitrates?
*Nitroglycerin SL, isosorbide dinitrate*
- Short midday appts
- Premed for stress reduction w/BZDP or N2O
- Limit epi to 0.04mg/2hr visit
- Keep SL nitro or spray in office
- Do angina history often
- Max office dose of nitro is 2 tabs, DO NOT give 3rd tablet if systolic BP is below 90mmHg
- Call 911 if chest pain not resolving after 10 min and 2 nitro tabs SL
- Halitosis with Isosorbide Dinitrate
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What are the major dental tx impacts of Antiarrythmics?
*amiodarone, digoxin, flecainide, sotalol*
- amiodarone: intx with fentanyl - causing hypotension, bradycardia & can increase lidocaine levels
- digoxin: dental drug intx (inc. by BZDP, erythromycin, tetracycline, ibuprofen) & recognition of dig toxicity
- all agents: represent “flag” for epi dosage limits, decreased stress tolerance & arrhythmia assessment
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What are the major dental tx impacts of Lipid lowering medications?
*atorvastatin, ezetimibe, gemfibrozil, lovastatin, Nicotinic acid, pravastatin, rosuvastatin,
simvastatin, Simvastatin/ezetimibe (Vytorin)*
- All agents: increase gag reflex and cause taste disturbances
- Statins: intx with macrolides and azole antifungals
- Statins: muscle pain and weakness can be orofacial
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What are the major dental tx impacts of Blood thinners?
*aspirin, clopidogrel, warfarin*
- Warfarin: drug intx (inc bleeding w/ASA, ABX, Metronidazole, Azole antifungals), guidelines for INR and dental treatment (Pts w/INR 1.5-3.5X normal can be managed w/o dose change but confirm on surgery day), avoid NSAIDs
- Dabigatran (Pradaxa): MOA, indications - reduce risk of stroke and systemic embolism in pts w/non-valvular atrial fibrillation, management - monitor bleeding
- Clopidogrel: antiplatelet so don’t discontinue, inc by NSAIDS
- ASA: antiplatelet so don’t discontinue, discontinue high-dose (2400mg/day) for 7 days before surgery
- Most patients will be managed with “local measures”
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What is the normal INR of person not on Warfarin?
1.0
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What is the therapeutic range for pts on Warfarin? Should you alter there Warfarin therapy?
- Therapeutic range (INR) = 2.0-4.0
- Warfarin does not need to be stopped and dose does not need to be adjusted before primary care dental surgical procedures for pts w/an INR <4.0.
- They may bleed more but this can easily be treated with local measures
- Risk of thromboembolism after withdrawl outweighs risk of oral bleeding
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