Review of top 10 prescribed drugs and their interaction with dental treatment

This summary is based on the article published in the Dental Clinics of North America: Review of Top 10 Prescribed Drugs and Their Interaction with Dental Treatment (April 2016)

Robert J. Weinstock, DDS; Michael P. Johnson, DMD

• The top 10 prescribed drugs and their interactions with dental treatment are reviewed.
  
• This article demonstrates the different ways drugs may interact with dental treatment for example, side effects, drug–drug interactions.
  
• This article facilitates analysis of any drug and what to seek out when considering relevant drug interactions with dental treatment.

LEVOTHYROXINE

• Levothyroxine is a thyroid hormone supplement.
• For the well-controlled hypothyroid patient taking a longstanding stable dose of levothyroxine, there are no specific interactions between levothyroxine and dental treatment.
• For patients who are recently diagnosed with hypothyroidism and are not yet euthyroid, elective treatment is best deferred and emergent treatment carried out with caution.⁷ The concern is that the thyroid levels are too high then thyrotoxicosis can ensue.
• There are interactions with levothyroxine and warfarin, ketamine, and carbamazepine:
  • Levothyroxine increase the International Normalized Ratio (INR).
  • Levothyroxine may increase the hypertension and tachycardia that occurs with administration of ketamine 422 Weinstock & Johnson during parenteral sedation.
  • Carbamazepine may increase thyroid hormone metabolism; thus, patients initiating these medications may need an adjustment of their levothyroxine dose.⁷

ACETAMINOPHEN WITH HYDROCODONE

• Opioids are central for pain management of the dental patient, especially when other medications such as nonsteroidal antiinflammatory drugs (NSAIDs) are inadequate.
• There are no specific interactions between hydrocodone/APAP with dental procedures or local anesthetics. However as dentists will be prescribing opioids for perioperative pain management, there are certain important considerations.
• Patients on chronic opioids
  • The dentist is cautioned against prescribing increased doses of opioids for patients on chronic opioids because the incidence of sedation is higher in the chronic opioid group²² and without frequent clinical monitoring it may be difficult to identify the appropriate postoperative opioid dose.
  • The dentist is encouraged to consider the use of long acting local anesthetics, preemptive analgesia, and perioperative NSAIDs to mitigate the postoperative analgesic requirement required by the patient.
• Patients with hepatic impairment
  • The use of APAP in patients with compromised hepatic function is controversial: APAP toxicity has been reported to occur more easily with compromised hepatic function due to patients being more sensitive to the toxic metabolites of APAP and having compromised ability to eliminate the toxic metabolites.²³
  • It is recommended that patients with cirrhosis not exceed a daily limit of 2000 mg APAP.^20,25,27
• Drug–drug interactions
  • Patients who are poor metabolizers via CYP2D6 experience no analgesia from hydrocodone.³⁰
  • Patients who are concomitantly taking other narcotics, antihistamines, anxiolytics, and other central nervous system depressants should use caution when taking hydrocodone, because the central nervous system depression is additive.¹⁷

LISINOPRIL

• Lisinopril belongs to the class of antihypertensive agents called angiotensin-converting enzyme inhibitors (ACEi) and has extensive applications in the management of cardiovascular disease.³¹
• Cumulative evidence recommends discontinuation of the ACEi the morning of surgery; however, modification of anesthetic induction technique may possibly ameliorate the hypotensive effects of concomitant ACEi use and anesthetics.³⁹
• The side effects of ACEi are pertinent to the general dentist potentially affecting the process of care delivery. The specific side effects include postural hypotension, coughing, and angioedema, with angioedema potentially being life threatening.
• Drug–drug interactions
  • Patient on ACEi should not take NSAIDs for perioperative pain management for longer than 5 days because NSAIDs may decrease the effectiveness of the antihypertensive effects of the ACEi.⁵¹

METOPROLOL

• The indications for metoprolol include management of hypertension, angina pectoris, and to reduce mortality from myocardial infarction.^55,56
• Cardioselective beta-blockers have less dental-related interaction than nonselective beta-blockers.
• As with ACEi, metoprolol can cause orthostatic hypotension; therefore, patients should be moved slowly from a supine to an upright position.
• Metoprolol may also cause xerostomia, dysgeusia, and oral lichenoid reactions. NSAIDs taken by those on metoprolol may reduce the antihypertensive effects of metoprolol.⁴²

ATORVASTATIN AND SIMVASTATIN

• Atorvastatin and simvastatin belong to the group of cholesterol-reducing drugs known as hydroxymethylglutaryl-coenzyme A reductase inhibitors.
• Cholesterol reducing medications are designed to reduce the morbidity and mortality of coronary heart disease by reducing total cholesterol, lowdensity lipoprotein cholesterol, triglycerides, and increasing the high-density lipoprotein cholesterol.
• There are no specific interactions between dental treatment and patients taking these statins.
• Dentists should, however, be cognizant of certain drug–drug interactions with these statins.
• Patients taking coumadin may have elongation of their INR when starting simvastatin; this interaction is not seen with atorvastatin.^61,62,65
• Drugs that the dentist may prescribe that interact with atorvastatin and simvastatin include itraconazole, ketoconazole, erythromycin, and clarithromycin.
• The adverse effects of statins, especially when taken with a CYP3A4 inhibitor, include myopathy and muscle weakness that, if severe, can result in rhabdomyolysis and acute renal failure.
• Confirmation of statin induced myopathy is confirmed by history and elevation of creatinine phosphokinase.⁶⁷

AMLODIPINE

• Amlodipine belongs to the class of antihypertensives referred to as calcium channel blockers (CCB) and is commonly prescribed for the treatment of hypertension and angina without congestive heart failure.
• Amlodipine-induced gingival enlargement
  • Reports of amlodipine associated gingival enlargement has been shown primarily at higher doses (in excess of 10 mg per dose) and in patients with poor plaque control.
  • A discussion with the prescribing physician should explore the possibility discontinuing or substituting the offending medication. With plaque control and drug cessation, most cases respond favorably. Severe cases may require gingivectomy.
• Hypotension after coprescription of macrolide antibiotics
  • Patients taking amlodipine are at increased risk for hypotension after the use of clarithromycin or erythromycin, but not azithromycin.

METFORMIN

• Metformin is a first-line drug of choice for the treatment of type 2 diabetes mellitus, in particular, in overweight and obese people and those with normal kidney function.
• Long-term use of metformin may result in vitamin B₁₂ deficiency. Vitamin B12 deficiency may manifest as altered taste, “burning,” or “sore” tongue, and/or enlarged or altered tongue appearance.
• Patients on metformin can very rarely develop angioedema, which would present as a facial or tongue swelling. This is considered a medical emergency, and if a patient presents as such to a dental office, where angioedema is suspected, the patient should be sent to the emergency department.

OMEPRAZOLE

• Omeprazole is a proton pump inhibitor used in the treatment of dyspepsia, peptic ulcer disease, gastroesophageal reflux disease, laryngopharyngeal reflux, and Zollinger–Ellison syndrome.
• Coadministration of omeprazole with warfarin should be avoided because it may increase the effects of warfarin.⁷⁸ Dental patients on warfarin who may be self-prescribing omeprazole should be monitored before treatment.
• Dentists who prescribe antibiotics known to cause CDAD should remind patients of the risk of diarrhea that does not improve.
• Hypomagnesemia has been reported in patients on omeprazole.⁸⁰ Magnesium deficiency may cause weakness, muscle cramps, arrhythmias, depression, tetany, and mental status changes.

ALBUTEROL

• Albuterol is a short-acting b2-adrenergic receptor agonist used for the relief of bronchospasm in conditions such as asthma and chronic obstructive pulmonary disease. Albuterol is also prescribed to prevent breathing difficulties—secondary to bronchoconstriction—during exercise.⁸¹
• A common side effect of albuterol is tremor, but patients can experience tachycardia or palpitations after use.
• Chronic use of albuterol is known to cause xerostomia in patients, which can lead to an increased caries risk, gingivitis, increased periodontal disease risk, compromised enamel.
• The risk for oral candidiasis increases with the use of albuterol.

References

List of References (PDF)