"THE MEDICALLY COMPROMISED PATIENT & COMMONLY USED PRESCRIPTION DRUGS"
THE MEDICALLY COMPROMISED PATIENT & COMMONLY USED PRESCRIPTION DRUGS Entire textbooks have been written describing the topic of this short discussion. Obviously, the entire area can hardly be covered in such a short time. What we would like to do, however, is to touch upon a few important issues and to place the entire area into a more easily understood context. Strategic Reserve: Normal, healthy people have built in levels of strategic physiologic reserve as it relates to the functioning of the various organ systems. This fact is taken advantage of in organ transplantation in that a close relative of a kidney patient may be an organ donor, giving up a kidney and yet function essentially normally for the rest of his or her life. The amount of reserve varies, but in general, nature has built a surplus into each system. As a rule, nature generally does not do things wastefully and this strategic reserve handles the "overload" or increase in need as the individual is challenged by various stresses. These stresses may take many forms, such as physical privation during periods of starvation, injury following a motor vehicle accident, or the flight or fright response when faced with anxiety provoking situations such as dental treatment. In the last example, both pulse and blood pressure are raised, the pupils dilated, the skin cool and clammy and the patient is ready to bolt at the slightest provocation. Nature has built into the autonomic nervous system and the cardiovascular system, the ability to "rise to the occasion" of impending threat with a temporary tapping of that latent reserve in order to meet this threat. Systemic Illness and Loss of Strategic Reserve: When viewed in this context, each system has such a reserve, but this reserve is finite. The system can only tap its reserves so much in the face of threat and when this reserve is exhausted, failure of the system in imminent. In the medically compromised patient, this reserve is diminished as a function of chronic disease such that the patient’s ability to "rise to the occasion" is diminished. The patient is less capable of dealing with stress and prone to medical crisis. In the office setting this is not a practice builder. For clarity, we have elected to discuss loss of strategic reserve, or illness, on a scale of 1 to 4. For example, angina may be classified as follows: Class 1: angina on extreme exertion (climbing 10 flights of stairs) Class 2: angina on moderate exertion (climbing 2 flight of stairs) Class 3: angina with normal activity (walking down the street) Class 4: angina at rest (sitting watching TV) As this example illustrated, the patient's strategic reserve diminishes as disease progresses and the stress needed to induce angina decreases. This simple classification system can be used for a number of other diseases as well. We have selected the following as some of the more common. Table I: Disease Classification by Symptoms or Description Disease Class 1 Class 2 Class 3 Class 4 Myocardial angina with angina with angina with angina at Ischemic extreme moderate minimal rest Disease exertion exertion exertion or or or or MI > 2 yrs MI < 2 yrs MI < 1 yr MI<6mths Congestive SOB with SOB with SOB with SOB at rest Heart extreme moderate minimal Failure exertion exertion exertion Hyper- diastolic diastolic diastolic diastolic tension >90 >95 >100 >110 <95 <100 <110 or or or or no symptoms minimal moderate severe symptoms symptoms symptoms (headache) (CHF) (stroke) Asthma cannot find uses puffer uses puffer uses puffer puffer monthly weekly daily COPD SOB with SOB SOB SOB extreme moderate minimal at rest exertion exertion exertion Diabetes diet oral hypo- controlled brittle controlled glycemics with insulin diabetic or or or or no symptoms minimal moderate severe symptoms symptoms symptoms (neuropathy) (blurry vision) (amputations or MI or blind) Bleeding on ASA on Coumadin on Coumadin hemophiliac with good control with poor control poorly controlled or or or or no symptoms minor bruising moderate severe bruising or bleeding or bleeding haemarthrosis A very useful way to assess a patient's disease state is to determine what medication they are taking. With most diseases, physicians use a staged or stair-stepped approach to pharmacological management. As the disease state worsens, The strength and number of drugs used tends to increase. Careful analysis of the patient's list of drugs usually indicates their medical diagnosis and further analysis will indicate how advanced this disease is. This is indicated for the above diseases with the following table: Table II: Disease Classification by Pharmacology 1. Myocardial Ischemic Disease Class 1 vasodilator PRN Class 2 vasodilator + vasodilator PRN prophylactically Class 3 vasodilator + vasodilator + B blocker PRN prophylac- tically Class 4 vasodilator + vasodilator + B blocker + calcium PRN prophylac- channel tically blocker examples nitro- Isordil Timolol Nifedipine glycerine nitropaste Labetolol Diltiazem Propranolol Verpamil 2. Congestive Heart Failure (CHF) Class 1 diuretic Class 2 diuretic + second diuretic Class 3 diuretic + second + inotrope diuretic Class 4 diuretic + second + inotrope + home diuretic oxygen examples Diazide Lasix Digoxin oxygen 3. Hypertension Class 1 B blocker Class 2 B blocker + diuretic Class 3 B blocker + diuretic + ACE inhibitor Class 4 diuretic + diuretic + ACE inhibitor +Ca channel blocker examples Timolol Diazide Captopril Nifedipine Labetolol Lasix Enalapril Diltiazem Propranolol Verapamil 4. Asthma Class 1 bronco- dilator Class 2 bronco- dilator + proph steroids Class 3 bronco- dilator + proph steroids + proph bronco-dilator Class 4 bronco- dilator + proph steroids + proph bronco-dilator + histamine vesicle stabilizer examples Ventolin Beclovent Theophylline Chromolyn 5. Chronic Obstructive Pulmonary Disease (COPD) Class 1 bronco- dilator PRN Class 2 bronco- + proph steroids dilator PRN Class 3 bronco- + proph steroids + proph bronco- dilator PRN dilator Class 4 bronco- + proph steroids + proph bronco- + antibiotics dilator PRN dilator & home oxygen examples Ventolin Beclovent Theophylline Ceclor (Theodur) Oxygen 6. Diabetes Class 1 diet Class 2 diet + oral hypo- glycemic Class 3 diet + oral hypo- + insulin glycemic (minimal dose change) Class 4 diet + oral hypo- + insulin + insulin glycemic (minimal (multiple hospital) hospital) examples CHO Glyburide Humulin Humulin restriction Diabinase NPH / Lente NPH / Lente 7. Bleeding problems (Bleeding diatheses / coagulopathies) Class 1 ASA Class 2 Coumadin INR < 1.5 Class 3 Coumadin INR > 1.5 Class 4 Haemophilia examples post MI for atrial previous (multiple Proph fibrillation DVT or hospitalizations) prosthetic valve Procedural Stress: From a systemic point of view, each procedure we do carries with it a certain level of stress to the patient. Simple procedures such as denture adjustments, examinations or radiographs carry minimal stress. More complex procedures such as scaling or root planing, simple restorations or impressions carry increased levels of demand on the system. Still more complex procedures such as lengthy crown and bridge appointments or extractions are increasingly stressful. Finally, complicated surgery such as difficult impactions or orthognathic surgery carry even greater levels of threat to the patient. The threat any given procedure presents to a patient may be magnified as a function of patient anxiety and this factor must also be taken into the equation. In general, a simple categorization of stress levels may be applied to given procedures: Level 1: denture adjustments, examinations or radiographs Level 2: scaling or root planing, simple restorations or impressions Level 3: lengthy crown and bridge appointments or extractions Level 4: difficult impaction or orthognathic surgery Our job as clinicians is to assess this reserve, to assess the threat to the system that our procedure represents and to make sure that we stay within the limits of the systems's ability to handle the threat. When procedural "threat", "stress" or "complexity" exceeds the patient's ability to handle the situation, we are faced with the potential for medical crisis. Careful assessment of risk allows us to avoid precipitating medical emergencies. For each system…fill in the blanks as you progress through the course: System Anatomy Physiology Disease Pathophysiology Symptoms Signs Therapy Pharmacology Failure