e. Psychiatric conditions (depression, eating disorders)
a. Clonazepam (Klonopin) 0.25-2mg/day (has peripheral effect)
b. Chlordiazepoxide (Librium) 10-30mg/day
2. Tricyclic Antidepressants
a. Amitriptyline (Elavil) 10-150mg/day
b. Nortriptyline (Pamelor)
a. Gabapentin (Neurontin) 300-1600mg/day
4. Capsaicin (OTC)
a. 1:2 dilution of hot pepper and water
b. Rinse w/ 1 teaspoon, increase strength to 1:1 dilution with time
Most commonly Used:
1. 10 multivitamins and minerals
a. Vit E, C, B12, A, D, Ca, Mg, Zn, Folic Acid
2. 10 herbal supplements
a. Echinacea, ginseng, gingko biloba, garlic, st. Jonh’s wort, peppermint, ginger, soy, chamomile, kava kava
3. Adverse reactions realted to herbs are due to inherent toxicity, overdose, drug-herb interactions and allergic responses
4. Patients must be asked if they are taking any dietary supplements or herbal rememdies along with their prescription drugs
5. Potential drug interactions should be identified
-Effective against dementia, leg claudication
-Anti-platelet activity causing spontaneous bleeding, GI complaints, headaches, allergies
-Interacts with MAOI, ASA, anti-PLT drugs and thiazide diuretics
-Used for hyperlipidemia
-Increased risk for bleeding, GI symptoms, be careful with anti-platelet drugs
-Used for nausea
-Caution with anti-platelet drugs St. John’s Wort
-Used for mild-moderate depression
-Causes GI symptoms, dizziness, confusion, tiredness, sedation, photosensitivity, inhibition of sperm motility, Many drug interactions due to liver drug metabolism
-Tx of menopausal symptoms and lowering cholesterol
-Concern for long-term estrogen effects Kava Kava
-Used as a sedative, relaxant
-Small benefit for anxiety
-Severe hepatotoxicity possible, combination with benzodiazepines may cause semicomatose state
-Contraindicated in multiple sclerosis, HIV infection and TB
-Physical and cognitive performance
-Interacts with Warfarin, MAO inhibitiors
-Don’t use with stimulants, anti-psychotic drugs or hormones
-Tx of IBS
-Sleep disorders, anxiety and GI problems
Drug incompatibilities of a physical or chemical nature - mixing of in the same bottle, tubing, syringe or IV drip
Usually involves drugs that are given parenterally for sedation (i.e., barbiturates and opioid analgesics)
When one drug affects the absorption, distribution, biotransformation or excretion of another drug
Many possible interaction with OTC drugs, antibiotic and antifungal agents
Modifications in the pharmacologic effects of one drug in the presence of another
Analgesics and epinephrine
Antacids and H2 blockers increase the
gastric absorption of
enteric coated medications
Antacids and H2 blockers prevent absorption
of pH sensitive drugs like
PCN, ketoconazole ,digoxin
Antacids that contain Ca++,
Mg++, Fe++, Al+++ and calcium enriched products interfere with
Oral anticoagulants are highly protein bound in plasma - easily displaced from their plasma protein binding site by:
certain antibiotics (sulfonamides)
analgesics/anti-inflammatory agents (aspirin)
Extended use of high dose aspirin (more than 4 days and more than 3 g/day) causes an increase in warfarin (Coumadin) potency and increases bleeding
_____ enhances the hepatic breakdown of a host of substances and it especially makes the standard dose of Coumadin ineffective
____ reduces plasma levels of protease inhibitors (HIV progression), cyclosporine (immune suppression), Coumadin (bleeding) and oral contraceptives (unwanted pregnancy)
St. John’s Wort
_____ which interferes with hepatic clearance of Coumadin (bleeding) and Lithium (renal toxicity)
__________ interfere with clearance of digoxin (causing bradycardia), theophylline (causing tachyarrhythmia), carbamazepine (causing CNS effects), prednisone (causing steroid toxicity), Coumadin (causing bleeding), cyclosporine (causing severe immune suppression & nephrotoxicity), terfenadine (causing severe tachycardia)
Erythromycin (and macrolides in general), azole antifungal drugs (Ketoconazole and Itraconazole) [and grapefruit juice]
______ can reduce digoxin metabolism in the gut causing toxicity (cardiac arrhythmia)
____ alters GI flora and reduces the absorption of the oral contraceptives (reduced birth control effect)
Rifampin is also a strong Cytochrome P450 inducer leading to rapid clearance of estrogen and progesterone
____ have a major inhibitory effect on hepatic clearance of sensitive drugs
___ & administration of exogenous epinephrine in local anesthetics can cause increased cardiac rate and output w/out the compensatory vasodilitation and an increase in patient’s blood pressure
Non-selective B-blockers block cardiac B1-adrenergic & and vascular B2-receptors;
___ anticoagulant effect is enhanced by the use of NSAIDs and ASA leading to upper GI bleeding
Heparin and Coumadin
Halothane(a general anesthetic) has a CNS depression effect that is enhanced by the use of
opioid analgesics (i.e., Morphine & Meperidine)
____ most likely inhibits serotonin reuptake so concomitant use with SSRIs (i.e., sertraline or Zoloft) can lead to serotonin toxicity
St. John’s Wort
Nabumetone (Relafen) and Naproxyn Sodium (Naprosyn
COX1 and COX2 inhibitors
suitable for joint inflammation without seriously impacting the stomach lining
Naproxyn seems to have a more salutary effect on headache than the other NSAID’s.
analogue of the tricyclic antidepressants and has similar side effects.
myalgia, myofascial pain and muscle spasms
Side Effects: sedation, postural hypo-tension and fainting.
Contraindications: liver or kidney disease alcoholism, near-term pregnancy.
Cross Rxn’s: Other TCA’s or SSRI, any drug which is hypotensive inducing, any sedating medication drug.
Alpha 2 Agonist
Dose range 2-8 mg tid
Increases synaptic inhibition of motor nuerons
Similar to Clonidine but 1/10 to 1/50 as potent on lowering blood pressure.
Useful for CTTH
Useful for MFP
Follow liver enzymes
Require Glucose-6-phosphate dehydrogenase to metabolize
Cannot use with any history of anemia (G6PD deficiency – the most common inherited enzyme pathology affecting more than 400 mil people).
Can cause oxidative damage to RBCs in G6PD deficient individuals.
In order to determine if a toothache is peripheral or central, the tooth and area around the tooth
should be thoroughly anesthetized.
Pain is continuous
Pain is aching and burning
Pain usually associated with static mechanical allodynia.
Pain responds to somatic blocking
chronic peripheral trigeminal neuropathy
persistent idiopathic facial pain of neuropathic origin that is characterized as aching or burning, a lowered response to neurosensory stimulation, is blocked by topical and or local anesthetics and is not due to another cause.
Topical Medications and Stents
Instruct patient to mix in equal portions:
Orabase Paste ( mucoadhesive with 20% benzocaine)
Apply to affected area 4-6x/day
If this shows any benefit, make stent.
If this procedure is helpful with stent but only partially, add other medications to the mixture
Other topical agents
Gabapentin up to 10% if being mixed with Orabase due to thickness and other agents.
Note: Use compounding pharmacist who uses a mill. Mortar and pestle processing will not make a powder fine enough.
Often triggered by chewing and swallowing.
Refractory to all conventional analgesics
Opiates only effective at high doses where patient is significantly sedated.
Sharp stabbing paroxysms of pain
Dull aching background pain.
Light touch will trigger the pain, e.g. washing face, brushing teeth, licking lip, talking, eating,
Marked by periods of remission.
Often pain stops when patient is asleep.
Goes into remission for weeks, months or years.
Most often in individual 50 and older.
Female to male prevalence 1.6:1
Less than 4% is bilateral
Neurological Exam is normal
trigger areas for trigeminal neuralgia
perioral region in V2 and V3
intraorally in the tooth or gingival regions
lateral border of the tongue
MRI w contrast, look for notches in trigeminal root where vessel sits on nerve
Medication Management for Trigeminal Neuralgia
RF or Glycerol gangliolysis
Microvascular decompression removes the offending blood vessel from the trigeminal root and places a teflon material over the nerve to protect the damaged area.
activating central sensitizing processes that have a tremendous impact on the character of the pain and its response to therapy.
Pain is not blockable
Dynamic Mechanical Allodynia
Chronic centralized trigeminal neuropathy
pain that is persistent, aching and/or burning, not responsive to topical or local anesthetic blocking and is due to central sensitization,
dental analogue = atypical odontalgia
Treatment of Centralized Neuropathic Pain
Sympathetically mediated pain
pain that is maintained by sympathetic efferent activity or circulating catecholamine action as determined by pharmacologic or sympathetic nerve blockade.
autonomic involvement, motor, cutaneous, sensory and dystrophic changes.
duration of AB therapy
Remission of disease + 48 hrs
Consider host factors; adjust for renal and hepatic diseases
penicillins and cephalosporins
Good diffusion in organic fluids, infected tissues
Most cross the placenta; excreted in breast milk
Resistance is an issue
Hypersensitivity, GI disturbance, anemia, renal damage
broad - most g+ and g- bacteria including many anaerobes (chlamydiae, rikettsia, spirochetes), even some protozoa