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JOE ALAMAT DDS, MD SUMMIT ORAL AND MAXILLOFACIAL SURGERY dralamat@yahoo.com (586)703-7104) Slide 2 Medication List Learn to decipher the patients medical history through medication lists. Know why they are on the medications What precautions should be taken Learn to think like the PCP. Slide 3 Topics that will be covered CVS Diabetes Immunocompromised Pregnancy Oral Cancer Osteoporosis Slide 4 Cardiovascular diseases Two disease entities will be covered: Hypertension Myocardial infarction Slide 5 Traditional Vs Functional Medicine Traditional medicine teaches us that hypertension is a disease that is diagnosed by elevated systolic and or diastolic pressures. Treatment is focused on decreasing the blood pressure readings by medications. Integrative medicine recognizes that hypertension is a symptom of underlying endothelial dysfunction secondary to inflammation and increased oxidative stress. Treats patients by exercise, diet, micronutrient replacement such as Zn, Vit C, in addition to medications Slide 6 Preload Afterload Ejection fraction Slide 7 HTN Patient presents for routine check up Bp is 175/95 HTN confirmed three time at least a week apart 140/90 or use ambulatory blood pressure monitors. Single diastolic reading of 110 is confirmation of HTN Slide 8 Complications of HTN The problems associated with HTN or increased afterload Heart has to pump with more force to overcome the pressure Cardiac hypertrophy and eventually left ventricular dysfunction develops End organ damage (fundoscopic, renal, brain) all associated with vascular damage Slide 9 How can we decrease the pressure in this closed system Decrease pump strength Increase the volume in arteries Increase volume in the veins Decrease fluid in the system Slide 10 Medications To Treat HTN Beta blockers (olols) decrease pump strength and speed Diuretics (Lasix, Lozol, HCTZ) decrease fluid in the system Ace inhibitors (prils) decrease the fluid resorption in the kidneys and prevents angiotensin from developing Slide 11 Medications To Treat HTN Calcium channel blockers (norvasc etc) increase the volume in the arteries ARBs block the vasoconstrictive effects of angiotensin Alpha antagonists (Terazosin) relax arteries and increase the volume of the arteries Centrally acting (Clonidine) decrease sympathetic outflow on the CVS Slide 12 Mild HTN easily controlled based on prescription Slide 13 Moderate to Severe Hypertension based on prescription Slide 14 How would you address a clearance The more meds a patient is on to control HTN, the more labile the HTN Avoid excessive epi Measure the BP Aspirate when injecting Calm environment Slide 15 Always Check the BP Slide 16 MI You are a cardiologist called to the cath lab for a patient with an STEMI. You determine that the LAD is occluded and decide to place a stent. What are the next steps of medical management? 6-8 Meds are always initially used. Slide 17 Mi Management Decrease the preload ( blood return to heart) with nitrates like nitrodur Slide 18 MI Management Decrease the afterload (so the heart is not pumping against high pressure so as not to stress the heart) BP meds ARB Ace inhibitor Beta blocker etc Slide 19 Mi Management Increase blood flow to the myocardium by using nitrates Slide 20 Mi Management Improve the lipid profile by using statins Slide 21 Lipid profile drugs Cholesterol lowering medications Lipitor (went generic) Zocor They are both statins decrease production of cholesterol Zetia decreases absorption Zocor and Zetia called Vytorin Others are Crestor and Niaspan and Tricor Slide 22 Mi Management Anticoagulate to prevent reocclusion of the stent and dissolve or prevent thrombotic emboli.(antiplatelets) Aspirin Plavix Slide 23 Anticoagulant Coumadin inhibits factors 10, 9, 7 and 2 from forming in the liver. Half life 20-60hours Pradaxa (dabigatran): reversibly and directly inhibits thrombin. Half life is 12-17 hours. No INR required. Xarelto (rivaroxaban) is a factor Xa inhibitor. Half life 5-9 hours. Slide 24 ADA council on scientific affairs stated that antiplatelet and anticoagulant meds rarely need to be discontinued prior to most dental procedures. The risk for thromboembolic events exceeds the risk of bleeding. Slide 25 Never stop Plavix or ASA after a recent MI Slide 26 MI management Regulate the speed of the heart so that arrhythmias do not develop. Slide 27 Beta Blockers Used to treat HTN, angina and Migraines Work on the beta receptors and block them, unlike asthma medications that stimulate the receptors Metoprolol (Lopressor) is a cardioselective med Slide 28 MI management Amiodarone for ventricular tachycardia Slide 29 Red Flags Coumadin s/p MI indicates significant ventricular dysfunction secondary to ischemia. Amiodarone suggests that the patient has a history of dangerous ventricular tachycardia and rhythm Slide 30 Dental clearance Increased risk of problems in the first 6 months status post MI Do Not stop Plavix or aspirin or coumadin No epi No Nsaids Ask if patient gets shortness of breath.(Functional Capacity) Slide 31 Diabetes Fasting Glucose 99 or below is normal 100 to 125 Pre-diabetes impaired fasting glucose 126 or above diabetes * * Random glucose above 200 Type I autoimmune Type two insulin resistance Slide 32 Metabolic Syndrome The dominant underlying risk factors for this syndrome appear to be abdominal obesity and insulin resistance. Insulin resistance is a generalized metabolic disorder, in which the body cant use insulin efficiently. This is why the metabolic syndrome is also called the insulin resistance syndrome Slide 33 Metabolic Syndrome Some people are genetically predisposed to insulin resistance. Acquired factors, such as excess body fat and physical inactivity, can elicit insulin resistance and the metabolic syndrome in these people. Most people with insulin resistance have abdominal obesity. Slide 34 Slide 35 Diagnosis is three or more Elevated waist circumference: Men Equal to or greater than 40 inches (102 cm) Women Equal to or greater than 35 inches (88 cm) Elevated triglycerides: Equal to or greater than 150 mg/dL Reduced HDL (good) cholesterol: Men Less than 40 mg/dL Women Less than 50 mg/dL Elevated blood pressure: Equal to or greater than 130/85 mm Hg Elevated fasting glucose: Equal to or greater than 100 mg/dL Slide 36 Manifestations of Metabolic Syndrome Skin Tags Acanthosis Nigrans Slide 37 Type of Obesity Central AdiposityGeneralized adiposity Slide 38 Diabetes meds Actos, Avandia Decreases insulin resistance Lantus Long acting injected insulin Byetta Increases insulin secretion Metformin Decreases absorption Slide 39 Treatment of diabetes Oral Hypoglycemic Insulin if resistant or level high Weight modification ACE inhibitors if protein is in the urine to protect the kidneys Usually associated with hypertriglyceridemia Usually treated with Niaspan Slide 40 Functional Medicine In addition to Medications, supplements are used. Zinc Chromium ALA Vit D (sequestered in fat) CoQ10 Omega 3 Sleep Decrease stress levels Low Glycemic Index foods Slide 41 Glycemic Index It measures how fast food raises the sugar level in the blood Glucose has a GI of 100. shoot for foods less than 55 E.g. Bagel 72 Cornflakes 93 Coco Pops 73 Rice Cakes 82 Pretzels 83 Ice cream 57 Apple 39 Fruit roll Ups 99 M&& peanut 33 Slide 42 Dental clearance issues Minimize NSAIDs Watch for hypoglycemia Watch carefully for infections( use cidal meds such as PCN Doc) Ask about their HBA1C Slide 43 Immunocompromised patients Patients that fall in this category are numerous. Among them are those on steroids over 20 of prednisone daily. Organ transplant patients Patients on chemotherapy Patients taking DMARDS( disease modifying anti rheumatic drugs) Slide 44 Slide 45 Transplant Patients Liver function is assessed by the PT which measures 1972. Ask about increased bleeding, bilirubin etc. If tests are okay then treat as an immunocompromised patient Kidney ask about the bun and creatinin. Should be 10, and 1 respectively. If tests okay treat as immunocompromised patient Heart Ask about EF and CHF. Slide 46 Transplant Patients Some of their meds include: Azathioprine Cellcept avoid motrin Cyclosporine avoid emycin, motrin Immuran Prograf avoid emycin, motrin GVHD lichenoid reactions Slide 47 DMARDS Are used for autoimmune diseases such as chrons disease, psoriasis, rheumatoid arthritis etc. Newer ones include TNF Inhibitors. These can be Mabs such as: Adalimumab (Humira) Golimumab (Simponi) Infliximab (Remicaide) Or fusion proteins such as: Etanercept (Enbrel) Slide 48 What are the MABS They are drugs that are Monoclonal AntiBodies. They are from animals Rats- AMAB Hamster-EMAB Primate- IMAB Mouse- OMAB Human-UMAB From human and animal mixed thus they are called chimeric XIMAB (Constant part is human) ZUMAB (variable is human) They are used in Cancer treatment, autoimmune disease, osteoporosis, and many other uses. Slide 49 Immunocompromised patients Beware of infections consider premedication Be aware of transient bacteremia from poor oral hygiene Do not give NSAIDS Do not give erythromycin or Z packs DOC is tylenol or Ultram Pen vk is DOC Clinadamycin if that doesnt work Slide 50 Pregnancy Not a contraindication to treatment. Important points are pen vk, clindamycin are allowed Tylenol3, tylenol, vicodin are all permitted Absolutely no NSAIDS or steroids. Steroids are teratogenic NSAIDS shut down the ductus arterosis. Minimize epi. That is what is in a clearance. Slide 51 Cancer Patients Prior to undergoing chemo treat any potential source of infection. Be aggressive During chemo therapy treat only emergencies. They are at high risk of fulminant infections and surgery sites heal very slowly Use cidal antibiotics such as penicillin as first therapy Arimidex or tamoxifen are used for ongoing breast CA treatment Leupron for prostate CA Slide 52 Cancer Patients Extract any tooth that is in the line of the beam if radiation therapy is to be done always at a risk for ORN Fluoride trays must be made Cleanings and exam every three months. Note about HPV (Cetiximab or Erbitux) Slide 53 Osteoporosis In osteoporosis, the bone mineral density (BMD) is reduced and bone microarchitecture deteriorates. Osteoporosis is defined by the World health organization (WHO) as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults) as measured by dual energy X ray absorptiometry Slide 54 Calcium Metabolism Slide 55 Osteoporosis Medications Slide 56 Bisphosphonates At this time, FDA believes that the benefits of oral bisphosphonate drugs in reducing the risk of serious fractures in people with osteoporosis continue to outweigh their potential risks. The agencys analysis, which found little if any benefit from the drugs after three to five years of use Slide 57 Bisphosphonates Actonel (risedronate) PO Aredia (pamidronate) IV Boniva (ibandronate) IV Fosamax (alendronate) Reclast (zolendronate) once a year for osteoporosis IV Skelid (tiludronate) PO Zometa (zolendronate) Once a month for cancer IV Slide 58 Osteoporosis drug may reduce colon cancer risk Mayo clinic health letter 2011 Jul;29(7):4. Slide 59 Oral Bisphosphonates and the Risk of Esophageal Cancer Exposure to bisphosphonates may be associated with an increased risk of esophageal cancer. More studies are needed to confirm the relationship. Aliment Pharmacology Ther. 2012 Oct;36(8):708-16. doi: 10.1111/apt.12041. Epub 2012 Sep 11. Slide 60 Bisphosphonate Use and Gastrointestinal Tract Cancer Risk Oral bisphosphonate use had no significant effect on gastrointestinal cancer risk. However, this finding should be validated in randomized controlled trials with long-term follow-up. World J Gastroenterology 2012 Oct 28;18(40):5779-88. doi: 10.3748/wjg.v18.i40.5779. Slide 61 Prolia (Denusomab) Prolia( denosumab)fully human monoclonal antibody denosumab inhibits osteoclast development, function, and survival Inhibits the RANKL protein that acts as the primary signal for bone removal Slide 62 SERMS Viviant(bazedoxifene) and Evista(raloxifene) are oral selective estrogen receptor modulators (SERM) that have estrogenic actions on bone and anti-estrogenic actions on the uterus and breast. Estrogen is responsible for increased BMD Slide 63 Forteo Forteo( teriparatide) parathyroid hormone analogue PTH increases serum calcium, partially accomplishing this by increasing bone resorption. Thus, chronically elevated PTH will deplete bone stores. However, intermittent exposure to PTH will activate osteoblasts more than osteoclasts. Thus, once-daily injections of teriparatide have a net effect of stimulating new bone formation leading to increased bone mineral density Slide 64 Tylenol VS NSAIDs which is better They both work well But avoid NSAIDs in older patients due to kidney and GI concerns. Avoid in diabetics and renal patients. Contraindicated in pregnancy Slide 65 RED FLAGS Shortness of breath BP above 200/100 Wheezing that doesnt resolve after two puffs of albuterol Cirrhosis patients Patients on amiodarone do not give epi Transplant patients do not give motrin or erythromycin Slide 66 Red Flags MI in the last 6 months Pregnant patients are not red flags