Download Pharmacologic Management of the Geriatric Patient

Pharmacologic Management of the Geriatric Patient: Practice Considerations for
Oral Healthcare Professionals
Special Care in Dentistry, New Orleans April 20, 2013
Ann Eshenaur Spolarich, RDH, PhD
[email protected]
Where do I find good information about drugs and herbs?
Lexi-Comp www.lexi.com
Drug Information Handbook for Dentistry; Authors: Wynn R, Crossley H and Meiller T
Lexicomp Online; Lexi-Interact Online (subscriptions)
Oral Soft Tissue Diseases; Authors: Newland RJ, Meiller T, Wynn R, Crossley H
Dental Drug Reference with Clinical Implications; 2nd edition; Authors: Frieda Atherton
Pickett and Geza Terezhalmy; Lippincott Williams & Wilkins
National Center for Alternative and Complementary Medicine http://nccam.nih.gov/
Natural Standard Research Collaboration (subscription) http://www.naturalstandard.com/
1.
3.
5.
7.
9.
11.
13.
15.
17.
19.
hydrocodone and acetaminophen
levothyroxine sodium
Lipitor
Plavix
azithromycin
Nexium
metoprolol tartrate
Synthroid
Proair HFA
trazodone HCl
INDICATIONS
pain relievers
hypercholesterolemia
hypertension
adverse thromboembolic events
endocrine disorders
antibiotics
antidepressants
GERD, reflux or hypersecretory disease
respiratory disease
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4.
6.
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14.
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18.
20.
hydrocodone and acetaminophen
lisinopril
simvastatin
Singulair
Crestor
levothyroxine sodium
hydrocodone and acetaminophen
Lexapro
ibuprofen
amoxicillin
DRUGS
hydrocodone and acetaminophen,
ibuprofen
Lipitor, simvastatin, Crestor
lisinopril, metoprolol
Plavix
levothyroxine, Synthroid
amoxicillin, azithromycin
Lexapro, trazodone
Nexium
Singulair, ProAir HFA
Source: Top 200 Medications for 2011. Source: IMS Health. Available at:
http://www.pharmacytimes.com/publications/issue/2012/July2012/Top-200-Drugs-of-2011
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Popular Herbs and Supplements
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A national survey conducted in 2007 found that 17.7% of American adults had used
"natural products" in the past 12 months
o dietary supplements other than vitamins and minerals
The most popular products used by adults for health reasons in the past 30 days
were:
o fish oil/omega 3/DHA (37.4%)
o glucosamine (19.9%)
o echinacea (19.8%)
o flaxseed oil or pills (15.9%)
o ginseng (14.1%)
52% of adult respondents said they had used some type of supplement in the last 30
days
o multivitamins/multiminerals (35%)
o vitamins E and C (12-13%)
o calcium (10%)
o B-complex vitamins (5%)
Barnes PM, Bloom B, Nahin R. Complementary and alternative medicine use among adults and children: United
States, 2007. CDC National Health Statistics Report #12. 2008.
Supplement Use in Seniors
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130 study participants (mean age 71.4 years)
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prevalence of polypharmacy: 72.3% (n = 94)
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38.5% (n = 50) taking five or more medications
 major polypharmacy
o 16.2% (n=21) reported taking two or more herbs
 polyherbacy
o 26.2% (n=34) reported taking two or more vitamin/mineral supplements
o 6.9% (n=9) reported using two or more nutraceuticals
46.2% (n = 60) at risk of having at least one potential drug-drug interaction
o
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31.5% (n = 41) at risk of having at least one possible drug and herbal-supplement
interaction
Loya, AM, González-Stuart, A, Rivera, JO. Prevalence of Polypharmacy, Polyherbacy, Nutritional Supplement Use
and Potential Product Interactions among Older Adults Living on the United States-Mexico Border: A Descriptive,
Questionnaire-Based Study. Drugs & Aging. May 5 2009; 26(5):423-436.
Supplement Use in Older Adults

Herbal product(s) and dietary supplements used
o Glucosamine or glucosamine/chondroitin
o Garlic
o Echinacea
o Gingko biloba
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o Herbal tea
o Cod liver oil
o St John's wort
o Ginseng
o Saw palmetto
o Other
A total of 90 different herbs or supplements were used by participants
Marinac JS, Buchinger CL, Godfrey LA, Wooten JM, Sun C, Willsie SK. Herbal Products and Dietary Supplements: A
Survey of Use, Attitudes, and Knowledge Among Older Adults. JAOA January 2007;107 (1):13-23.
Herbal Dietary Supplement (HDS) and Medication Interactions and Contraindications
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Identified 1,491 pairs of HDS-drug interactions
o 213 HDS
o 509 medications
Greatest number of documented interactions with medications:
o St. Johns wort
o magnesium
o calcium
o iron
o ginkgo
Of a total of 509 drugs, most were used for:
o CNS disorders (100)
o cardiovascular system disorders (90)
o systemic anti-infectives (75)
Greatest number of reported interactions with HDS:
o warfarin: most HDS interactions (100+)
o insulin
o aspirin
o digoxin
o ticlopidine
HDS products containing herbs were more likely to have documented interactions with
medications and contraindications than vitamins, minerals and other types of dietary
supplements.
152 identified contraindications
Most frequent contraindications involves:
 gastrointestinal (16.4%)
 neurological (14.5%)
 renal/genitourinary diseases (12.5%)
59 HDS were contraindicated for use among patients with specific disease states
Highest number of documented contraindications:
 flaxseed ( Linum usitatissimum)
 echinacea ( Echinacea purpurea)
 yohimbe ( Pausinystalia yohimbe)
Tsai HH, Lin HW, Simon Pickard A, Tsai HY, Mahady GB. Evaluation of documented drug interactions and
contraindications associated with herbs and dietary supplements: a systematic literature review. Int J Clin Pract.
2012:66(11):1056-1078.
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Flaxseed contraindications:
o acute/chronic diarrhea
o esophageal stricture
o inflammatory bowel disease
o hypertriglyceridemia
o prostate cancer
Ulbricht CE. Natural Standard Herbs & Supplement Reference: Evidence-Based Clinical Review. St Louis, MO:
Mosby/Elsevier, 2005.
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Echinacea contraindications:
o rheumatoid arthritis
o systemic lupus erythematosus
o leukosis
o multiple sclerosis
o tuberculosis
o HIV infection
Cassileth BR. Herb-Drug Interactions in Oncology. Lewiston, NY: BC Decker, Inc., 2003; Mahady GB. Botanical
Dietary Supplements: Quality, Safety and Efficacy. Lisse, The Netherlands: Swets & Zeitlinger Publishers, 2001.

Yohimbe contraindications:
o anxiety
o bipolar disorder
o depression
o mania and schizophrenia
o benign prostate hypertrophy
o kidney disease
Ulbricht CE. Natural Standard Herbs & Supplement Reference: Evidence-Based Clinical Review. St Louis, MO:
Mosby/Elsevier, 2005; National Center for Complementary and Alternative Medicine. Herbs at a Glance.
http://nccam.nih.gov/health/herbsataglance
It is estimated that > 50% of patients with chronic diseases or cancers use HDS
Miller MF, Bellizzi KM, Sufian M, Ambs AH, Goldstein MS, Ballard-Barbash R. Dietary supplement use in individuals
living with cancer and other chronic conditions: a population-based study. J Am Diet Assoc. 2008;108:483-94.
HERBAL MEDICATIONS AND BLEEDING
Many herbal preparations act like anti-platelet and anticoagulant medications
THE G’S (Ginkgo, Ginseng, Garlic, Glucosamine, Ginger)
Ability to antagonize PAF (Platelet Activating Factor) = potentially increase bleeding
Garlic
Uses: anti-lipidemic, antimicrobial, anti-asthmatic, anti-inflammatory
Components implicated in bleeding: volatile oil and ajoene
-ajoene is an unsaturated sulfoxide disulfide that is a component of allicin
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-allicin: a sulfinyl compound that gives garlic its strong odor and flavor
-effect of ajoene on platelets is irreversible: lasts for life of the platelet and
potentiates the effect of other platelet inhibitors (e.g. aspirin)
-several sulfur containing compounds isolated from garlic have also demonstrated
significant inhibition of human platelet aggregation
Effect: antiplatelet
-garlic oil exerts its effect on the archidonic acid pathway
-interrupting the synthesis of thromboxane
-stimulating the synthesis of prostacyclin
-decreases platelet aggregation and increases bleeding
-dose dependent effect
-occurs with both dietary garlic and garlic supplements
-alliin/allicin inhibit the production and/or release of chemical mediators: platelet
activating factor (PAF) and adenosine = decreases platelet function (strongest
sources of allicin is natural garlic clove)
Ginkgo
Uses: prevent decreased cerebral functions and peripheral vascular insufficiency associated
with Alzheimer’s disease or age-related dementia
Components implicated in bleeding: terpenoids (terpene ginkgolides)
-potent antagonists of PAF
-long-lasting effects and rapid onset with oral dosing
Effect: ginkgo increases prothrombin time and decreases platelet activity
-many case reports of severe bleeding episodes with ginkgo use
-patients taking warfarin and aspirin are at risk for severe spontaneous bleeding with
ginkgo use at recommended doses
Ginseng
Uses: anti-cancer, slows aging, prevent heart attack, improve digestion, reduce hypertension,
strengthen immunity, CNS stimulant
Components implicated in bleeding: ginsenosides
Effect: inhibit PAF, platelet aggregation, thrombin and thromboplastin
-antagonizes the effects of warfarin (decrease effectiveness)
-potentiate bleeding when combined with aspirin, NSAIDS, warfarin, heparin
Ginger
Uses: relive motion and morning sickness, decreases pain and inflammation with arthritis,
relieves upset stomach
Components implicated in bleeding: pungent principles (gingerol, shogaol, zingerone),
volatile oils (bisabolene, zingiberene, zingiberol) and proteolytic enzymes
Effect: reduces platelet thromboxane and inhibits platelet aggregation
-mixed reports in the literature: effects may be most significant with raw ginger
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Feverfew
Uses: anti-inflammatory (rheumatoid arthritis), Preventive for migraine headache, Muscle
soreness
Components implicated in bleeding: sesquiterpene lactone, parthenolide
Effect: inhibits platelet aggregation
Fish Oils
Uses: skin disorders, cardioprotection, diabetes, headache, immune support, memory, PMS,
ulcerative colitis, many others
Components implicated in bleeding: various derivatives of omega-3
Effect: Inhibit ADP-induced platelet aggregation. Increased bleeding time is suggested to
be due to either less thromboxane (TXA2) or higher prostacyclin I3 levels (antiaggregatory effects). Contradictory studies about effects on fibrinolysis and vascular
plasminogen levels.
St. John’s wort
Use: manage mild to moderate depression
Components implicated in bleeding: hypericin: induces cytochrome P450 liver enzymes
Effect: induction reaction of drugs in the liver
-reduces anticoagulant effect of warfarin (increases clotting)
-decreases the effects of many medications
Vitamin E
Use: fat soluble vitamin used as a dietary supplement
Antioxidant: prevents the oxidations of vitamins A and C; protects polyunsaturated fatty acids in
membranes from attack by free radicals; protects RBCs against hemolysis
Effect: may alter the effect of vitamin K on clotting factors, increasing hypoprothrombinemic
(prothombinopenia) response to warfarin = delayed clotting of blood or spontaneous
hemorrhage
HERB
COMMON USES
Echinacea
Common cold; cough
and bronchitis; wound
and burn care; urinary
tract infection
SOME SIDE EFFECTS AND
INTERACTIONS
Hepatotoxic, especially when used with other
hepatotoxic drugs; may decrease
effectiveness of corticosteroids
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Feverfew
Garlic
Ginseng
Kava-Kava
Licorice
St. John’s wort
Valerian
Vitamin E
Migraine prophylactic;
fever reduction; see
above
See above
Inhibits platelet activity; avoid use with
warfarin; 5-15% of users may develop
aphthous ulcers or GI tract irritation
Potentiates effects of warfarin; May
decrease effectiveness of certain HIV
protease inhibitor drugs
See above
Antiplatelet properties; Avoid use with
other stimulants: risk for tachycardia and
hypertension
Anxiolytic
Serious risks for hepatotoxicity; potentiates
alcohol, benzodiazepines, barbiturates =
caution with sedation and general
anesthesia
Gastric disorders;
Glycyrrhizic acid in licorice may cause
cough and bronchitis
hypertension and hypokalemia;
contraindicated with chronic liver
disease, renal insufficiency, hypokalemia
Depression and anxiety Decreases effectiveness of drugs for HIV:
protease inhibitors and non-nucleoside
reverse transcriptase inhibitors; induces
liver enzymes (altered drug metabolism);
prolongs effects of general anesthesia
(anecdotal reports)
Mild sedative; mild
Potentiates effects of barbiturates
anxiolytic
Antioxidant; CVD
Increased bleeding risk with other
prevention; wound
antiplatelet and anticoagulant medications;
healing; fibrocystic
may affect thyroid function in otherwise
breast syndrome
healthy person; may enhance
hypertension in hypertensive patients (≥
400 IU per day)
Source: American Society of Anesthesiologists. Considerations for Anesthesiologists: What you should know about your patients’
use of herbal medicines and other dietary supplements. 2003. Available at: www.ASAhq.org.
Dental Considerations
- Synergistic interactions may occur with antiplatelet drugs: aspirin, thienopyridines, NSAIDS
- Monitor patients who take warfarin (Coumadin) for herbal use and INR
-Cross-reference all herbal and prescription medications in a drug database to ensure
compatibility prior to prescribing
DRUGS THAT ALTER BLEEDING
ANTIPLATELET MEDICATIONS
-aspirin = antiplatelet drug
-blocks cyclo-oxygenase, an enzyme associated with clot formation
-inhibits platelet aggregation
-prevents thrombus formation on atherosclerotic plaques
-lowers risk of MI in those with increased risk for atherosclerosis/thrombogenesis
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-lowers risk of MI and stroke in those with previous history of MI and stroke, unstable
angina, post-coronary artery bypass grafting
-one enteric coated 325 mg tablet of aspirin daily or 81 mg low dose aspirin
Sudden Discontinuation of Aspirin
Discontinuing the use of aspirin increases mortality risk 1
Large clinical trial (n=1358) with hospitalized patients with an acute coronary syndrome 2
3 groups: never taken an oral antiplatelet agent (n=930), Hx of prior use (n=355),
recently discontinued use (n=73)
Among recently discontinued aspirin group, mostly due to physician recommendation
prior to surgery, there was a higher 30 day rate of death or MI and adverse bleedings
than among prior users
No difference in the incidence of death or MI at 30 days between nonusers and prior
users.
Recent withdrawal displayed worse clinical outcomes than nonusers.
1.
2.
Ho PM, Spertus JA, Masoudi FA, et al. Impact of medication therapy discontinuation on mortality after
myocardial infarction. Arch Intern Med. 2006 Sep 25;166(17):1842-7.
Collet JP, Montalscot G, Blanchet B, et al. Impact of prior use or recent withdrawal of oral antiplatelet
agents on acute coronary syndromes. Circulation. 2004 Oct 19;110(16):2361-7. Epub 2004 Oct 11.
A meta-analysis reviewing data from over 50,000 patients showed that aspirin nonadherence/withdrawal was associated with a three-fold higher risk for major adverse cardiac
events. 3
Risk was even greater among patients with coronary stents.
Risk was amplified by a factor of 89 in patient who had undergone stenting.
3. Biondi-Zoccai GG, Lotrionte M, Agostoni P, et al. A systematic review and meta-analysis on the hazards of
discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J. 2006
Nov;27(22):2667-74. Epub 2006 Oct 19.
other anti-platelet medications:
aspirin and dipyridamole (Aggrenox)
cilostazole (Pletal)
ticlopidine (Ticlid) – used for those who are intolerant to aspirin, when aspirin therapy has
failed, and coronary stent implantation
Lowers risk of stent thrombosis
Low risk of bleeding complications compared to other strategies
clopidogrel (Plavix)
Replaced use of ticlopidine
Lower rates of major adverse cardiac events and mortality compared with ticlopidine
Better safety-tolerability profile
Lower risk of neutropenia
Indications: reduce rate of TE (MI, stroke, vascular death) in patients with recent MI or
stroke; reduce rate of TE in patients with unstable angina managed medically or with
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PCI (with or without stents); reduces rate of death and TE in patients with ST-Segment
elevation MI managed medically
Dosing: 300 mg loading dose; 75 mg daily (with aspirin 81-325 mg daily)
Problems:
Drug interactions
Slow onset of action
Wide variability in patient response
Includes “no” response
prasugrel (Effient) *new drug approved in July 2009
Approved for patients with acute coronary syndromes undergoing PCI
Indications: Reduces rate of thrombotic cardiovascular events (eg, stent thrombosis) in
patients with unstable angina, non-ST-segment elevation MI, or ST-elevation MI
(STEMI) managed with percutaneous coronary intervention
Loading dose of 60 mg followed by maintenance dose of 10 mg
Manufacturer labeling states to also take 75-325 mg aspirin once daily upon
recommendation of provider
clopidogrel (Plavix) and prasugrel (Effient)
Prodrugs
Noncompetitive antagonists of P2Y12 receptor
Inhibit ability of adenosine diphosphate (ADP) to induce platelet aggregation and
decreases subsequent platelet aggregation
Block receptor for the life of the platelet = irreversible effect
action is independent of and additive to aspirin
Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary
artery stents: a science advisory from the American Heart Association, American College of
Cardiology, Society for Cardiovascular Angiography and Interventions, American College of
Surgeons, and American Dental Association, with representation from the American College of
Physicians.
Grines CL, Bonow RO, Casey DE Jr, Gardner TJ, Lockhart PB, Moliterno DJ, O'Gara P,
Whitlow P; American Heart Association; American College of Cardiology; Society for
Cardiovascular Angiography and Interventions; American College of Surgeons; American
Dental Association; American College of Physicians. William Beaumont Hospital, Royal Oak,
Michigan, USA. J Am Dent Assoc. 2007 May;138(5):652-5.
Abstract
BACKGROUND: and Overview. Dual antiplatelet therapy with aspirin and a thienopyridine has
been shown to reduce cardiac events after coronary stenting. However, many patients and
health care providers prematurely discontinue dual antiplatelet therapy, which greatly increases
the risk of stent thrombosis, myocardial infarction and death. CONCLUSIONS AND CLINICAL
IMPLICATIONS: This advisory stresses the importance of 12 months of dual antiplatelet therapy
after placement of a drug-eluting stent and educating patients and health care providers about
hazards of premature discontinuation. It also recommends postponing elective surgery for one
year, and if surgery cannot be deferred, considering the continuation of aspirin during the
perioperative period in high-risk patients with drug-eluting stents. PMID: 17473044
*Link to download full text copy: http://jada.ada.org/cgi/content/full/138/5/652
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3 Recommendations from Advisory Statement (listed above):
Those concerned about peri/postprocedural bleeding must be aware of catastrophic risks of
premature discontinuation
-Consult cardiologist to discuss optimal patient management strategies
Elective procedures with significant risk of peri/postoperative bleeding should be deferred
until patient has completed an appropriate course of thienopyridine therapy:
-12 months after DES implantation if they are not at high risk of bleeding
-Minimum of one month for bare-metal stent implantation
Patients with DES who are to undergo subsequent procedures that mandate discontinuation
of drug therapy, aspirin should be continued if at all possible
-Restart thienopyridine as soon as possible after the procedure because of concerns of
late stent thrombosis
NSAIDS
Ibuprofen has a very short half-life (2-4 hours)
Withhold for 4-6 half-lives prior to invasive dental surgical procedures (about 1 day
prior to treatment)
Cause bleeding as a side effect, especially GI bleeding
ANTICOAGULANT MEDICATIONS
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Antithrombins
o antithrombin
o heparin
Coumarin derivatives
o warfarin (Coumadin, Jantoven)
Thrombin inhibitors
o argatroban – px/tx of thrombosis with heparin-induced thrombocytopenia (HIT);
adjunct to PCI if at risk for HIT
o bivalirudin (Angiomax) – with ASA for unstable angina receiving PCI; undergoing
PCI with risk for HIT
o dabigatran etexilate (Pradaxa) – thromboprophylaxis for hip/knee replacement
o desirudin (Iprivask) – prophylaxis of DVT for hip replacement
o fondaparinux (Arixtra) – thromboprophylaxis for hip/knee replacement
o lepirudin (Refludan) – anticoagulation with HIT
o rivaroxaban (Xarelto) – thromboprophylaxis for hip/knee replacement
ANTITHROMBINS
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Antithrombin III (Atryn, Thrombate III)
o given to those with an antithrombin III deficiency
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Heparin
o enhances the inhibition rate of clotting proteases by antithrombin III impairing
normal hemostasis and inhibition of factor Xa
Low molecular weight heparins
o Use: prevention of DVT with or without PE; reduce risk for PE; acute unstable
angina; non-Q-wave MI
o Mechanism: Inhibit factor Xa and IIa (thrombin)
o Used following hip/knee replacement = at least 10 days and
 until risk for DVT has subsided or
 patient is adequately anticoagulated on warfarin
o Examples of LMW heparins:
 dalteparin (Fragmin)
 enoxaparin (Lovenox)
 tinzaparin (Innohep)
COUMARIN DERIVATIVES
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warfarin (Coumadin, Jantoven)
interferes with liver synthesis of vitamin-K dependent clotting factors
effects occurs in 4 to 5 days
when patient is admitted to hospital with stroke, there is a 1 to 2 day overlap period with
heparin following warfarin administration to prevent hypercoagulable state
o Heparin produces immediate effect
o Takes 4-5 days for effects of warfarin to occur
Indications for warfarin:
o Prophylaxis and treatment of TE disorders (venous and pulmonary) and embolic
complications that arise from atrial fibrillation or cardiac valve replacement
o Adjunct to reduce risk of systemic embolism (recurrent MI, stroke) after MI
Investigational: prevention of recurrent TIA
Many things can upset a patient’s level of anticoagulation from warfarin:
o Fever
o Flu
o Diarrhea or vomiting
o Use of many drugs, including antibiotics
o Change in diet (consumption of green leafy vegetables increases vitamin K
intake = promotes clotting)
 Need vitamin K to synthesize clotting factors in liver
 Warfarin shuts off production of these clotting factors
**Key messages: warfarin causes the greatest number of drug interactions
o Always check compatibility prior to issuing a prescription
o Always ask about the INR and monitor INR status across time to examine trends
in anticoagulation control
11
THROMBIN INHIBITORS
dabigatran (Pradaxa)
 FDA approved October 2010
 Thrombin inhibitor
 Prodrug = lacks anticoagulant activity
o converted in vivo to active dabigatran
 specific, reversible, direct thrombin inhibitor that inhibits both free and fibrin-bound
thrombin
 prevents thrombin-mediated effects, and by inhibiting thrombin-induced platelet
aggregation
 dabigatran inhibits coagulation by preventing thrombin-mediated effects, including
cleavage of fibrinogen to fibrin monomers, activation of factors V, VIII, XI, and XIII
 Indications:
 Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation
 Postoperative thromboprophylaxis after total hip or knee replacement
o Knee replacement – up to 10 days
o Hip replacement – up to 35 days
 compared to warfarin (Coumadin)
 advantages: no monthly monitoring; fewer drug-drug and drug-diet interactions
 disadvantages: very expensive; twice daily dosing
 in studies, patients who took Pradaxa had fewer strokes than those taking warfarin
o RE-LY trial = Randomized Evaluation of Long-Term Anticoagulation Therapy
 adverse effects: bleeding, GI effects
Indications for Direct Antithrombins (Thrombin Inhibitors)
 Prevent/reduce ischemia with unstable angina
 Prevent DVT following hip replacement
 Prevent/treat thromboembolism
 Treatment of heparin-induced thrombocytopenia (HIT)
rivaroxaban (Xarelto) (riv a ROX a ban)
 New drug – FDA approval announced July 1, 2011
 First and only oral anticoagulant approved in US for orthopedic surgery
 Factor Xa inhibitor
 Mechanism: inhibits platelet activation and fibrin clot formation via direct, selective, and
reversible inhibition of factor Xa in both the intrinsic and extrinsic coagulation pathways
 Indications:
o Postoperative thromboprophylaxis in patients who have undergone hip or knee
replacement surgery
 Adults: Postoperative thromboprophylaxis:
o Knee replacement: 10 mg once daily; recommended total duration of therapy: 1214 days
o Hip replacement: 10 mg once daily; total duration of therapy: 35 days
fondaparinux (Arixtra) (fon da PARE i nuks)
 Factor Xa inhibitor
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o causes an antithrombin III-mediated selective inhibition of factor Xa
Interrupts the blood coagulation cascade and inhibits thrombin formation and thrombus
development
Indications:
Prophylaxis of deep vein thrombosis (DVT) in patients undergoing surgery for hip
replacement and knee replacement
hip fracture (including extended prophylaxis following hip fracture surgery)
abdominal surgery (in patients at risk for thromboembolic complications)
treatment of acute pulmonary embolism (PE)
treatment of acute DVT without PE
Usual duration: 5-9 days
o up to 10 days following abdominal surgery
o up to 11 days following hip replacement or knee replacement
Extended prophylaxis is recommended following hip fracture surgery
o has been tolerated for up to 32 days total
Acute DVT/PE treatment:
o Note: Start warfarin on the first treatment day and continue fondaparinux until
INR is between 2 and 3 (usually 5-7 days) (Hirsh, 2008)
COMMON ORAL PROBLEMS IN ELDERLY PATIENTS
Drug classes that produce neural effects on the salivary glands
The following are examples of anticholinergic drugs that reduce the volume of serous saliva:
Antidepressants
Antiemetics
Antihistamines
Anti-parkinsonian drugs
Antipsychotics
Antispasmodics
Antihypertensives
The following are examples of sympathomimetic drugs that produce a viscous, mucinous saliva:
Amphetamines
Appetite suppressants
Bronchodilators
Decongestants
Sources: Sreeby LM, Schwartz SS: A reference guide to drugs and dry mouth, 2 nd ed, Gerodontol 14:33-47, 1997;Porter SR,
Scully C, Hegarty AM: An update of the etiology and management of xerostomia, Oral Surg Oral Med Oral Pathol Pral Radiol
Endod 97:28-46, 2004; Nähri TO, Meurman JH, Ainamo A: Xerostomia and hyposalivation: causes, consequences and
treatment in the elderly, Drugs & Aging 15:103-116, 1999.
Drug classes associated with causing xerostomia
Antiacne agents
Antianxiety agents
Anticholinergics/Antispasmodics
Anticonvulsants
Antidepressants
Antidiarrheals
Antiemetics
Antihistamines
Antihypertensives
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Anti-inflammatory analgesics
Antinauseants
Anti-parkinsonian agents
Antipsychotics
Anorexiants
Bronchodilators
Decongestants
Diuretics
Muscle Relaxants
Opiate Analgesics
Sedatives
Source: USP DI® Drug Information for the Healthcare Professional, vol 1, ed. 24, Englewood, CO, Micromedix, Inc., 2004.
Taste and Smell Disorders
Drugs that alter taste
Alcohol detoxification agents
Alzheimer’s medications
Analgesics (NSAIDS)
Anesthetics (general and local)
Anorexiants
Antacids
Antianxiety agents
Antiarthritics
Anticholinergics
Anticonvulsants
Antidepressants
Antidiabetics (oral hypoglycemics)
Antidiarrheals
Antiemetics
Antifungals
Antigout medications
Antihistamine (H1) antagonists
Antihistamine (H2) antagonists
Antihyperlipidemics
Antiinfectives
Anti-inflammatory/antiarthritics
Antimigraine agents
Antiparkinson agents
Antipsychotics
Antithyroid medications
Antivirals
Anxiolytics/sedatives
Asthma preventives
Bronchodilators
Calcium-affecting drugs
Cancer chemotherapeutics
Cardiovascular medications
CNS stimulants
Decongestants
Diuretics
Glucocorticoids
Gallstone solubilization agents
Hemorheologics
Immunomodulators
Immunosuppressants
Irritable bowel syndrome medications
Methylxanthines
Nicotine replacement drugs
Ophthalmics
Proton pump inhibitors
Retinoids, systemic
Salivary stimulants
Skeletal muscle relaxants
Vitamins
Source: Gage TW, Pickett FA: Mosby’s dental drug reference, ed. 7, St. Louis, 2005, Elsevier Mosby.
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Systemic drugs associated with lichenoid drug reactions
Category
Agents
Analgesic agents
NSAIDs, propoxyphene/acetaminophen, acetaminophen/codeine
Antianxiety drugs
benzodiazepines
Antiarrhythmics
quinidine
Anticonvulsant drugs
Depakote
Antineoplastic drugs
levamisole
Cardiovascular agents
Beta-adrenergic blockers, angiotensin II antagonist, calcium
channel blockers, cardiac glycoside, methyldopa, thiazide
diuretics, potassium supplements
Gastric acid secretion inhibitors H2-antagonists
Hormone replacement
Thyroid hormone, insulin, sulfonylureas, metformin, oral
contraceptives, estrogen, progesterone
Photographic Dyes
Uricosuric agent
Allopurinol
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