11: L

L

labetalol hydrochloride

la-bet′-ah-lole high-droh-klor′-ide

(Normodyne, Presolol[aus], Trandate)

Do not confuse Trandate with tramadol or Trental.

Category and Schedule

Pregnancy Risk Category: C (D if used in second or third trimester)

Drug Class:

Nonselective adrenergic β-blocker and selective α₁-blocker; antihypertensive

Mechanism of Action

An antihypertensive that blocks α₁-, β₁-, and β₂ (large doses)-adrenergic receptor sites. Large doses increase airway resistance.

Therapeutic Effect: Slows sinus heart rate; decreases peripheral vascular resistance, cardiac output, and B/P.

Uses

Treatment of mild-to-severe hypertension

Pharmacokinetics

Completely absorbed from the GI tract. Protein binding: 50%. Undergoes first-pass metabolism. Metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: PO, 6–8 hr; IV, 5.5 hr.

Indications and Dosages

Hypertension

PO

Adults.

Initially, 100 mg twice a day adjusted in increments of 100 mg twice a day q2–3 days. Maintenance: 200–400 mg twice a day. Maximum: 2.4 g/day.

Elderly.

Initially, 100 mg 1–2 times a day. May increase as needed.

Severe Hypertension, Hypertensive Emergency

IV

Adults.

Initially, 20 mg. Additional doses of 20–80 mg may be given at 10-min intervals, up to a total dose of 300 mg.

IV Infusion

Adults.

Initially, 2 mg/min up to total dose of 300 mg.

PO (after IV therapy)

Adults.

Initially, 200 mg; then, 200–400 mg in 6–12 hr. Increase dose at 1-day intervals to desired level.

Side Effects/Adverse Reactions

Frequent

Drowsiness, difficulty sleeping, unusual fatigue or weakness, diminished sexual ability, transient scalp tingling

Occasional

Dizziness, dyspnea, peripheral edema, depression, anxiety, constipation, diarrhea, nasal congestion, nausea, vomiting, abdominal discomfort

Rare

Altered taste, dry eyes, increased urination, paresthesia

Precautions and Contraindications

Bronchial asthma, cardiogenic shock, second- or third-degree heart block, severe bradycardia, uncontrolled CHF

Example: Labetalol hydrochloride (generic name), 100 mg

Caution:

Major surgery, lactation, diabetes mellitus, renal disease, thyroid disease, COPD, well-compensated heart failure, CAD, nonallergic bronchospasm

Drug Interactions of Concern to Dentistry

• Decreased metabolism: lidocaine

• Decreased effect: sympathomimetics

• Decreased hypotensive effects: indomethacin and other NSAIDs

• Increased hypotension, myocardial depression: hydrocarbon-inhalation anesthetics

• Increased plasma levels: diphenhydramine

Serious Reactions

! Labetalol administration may precipitate or aggravate CHF because of decreased myocardial stimulation.

! Abrupt withdrawal may precipitate ischemic heart disease, producing sweating, palpitations, headache, and tremors.

! May mask signs and symptoms of acute hypoglycemia (tachycardia, B/P changes) in patients with diabetes.

Dental Considerations

General:

• Monitor vital signs at every appointment because of cardiovascular side effects.

• Patients on chronic drug therapy may rarely have symptoms of blood dyscrasias, which can include infection, bleeding, and poor healing.

• Assess salivary flow as a factor in caries, periodontal disease, and candidiasis.

• Limit dose of vasoconstrictors, or avoid use of vasoconstriction.

• After supine positioning, have patient sit upright for at least 2 min before standing to avoid orthostatic hypotension.

• Limit use of sodium-containing products, such as saline IV fluids, for patients with a dietary salt restriction.

• Stress from dental procedures may compromise cardiovascular function; determine patient risk.

• Short appointments and a stress-reduction protocol may be required for anxious patients.

Consultations:

• Medical consultation may be required to assess disease control and patient’s ability to tolerate stress.

• In a patient with symptoms of blood dyscrasias, request a medical consultation for blood studies and postpone dental treatment until normal values are reestablished.

Teach Patient/Family to:

• When chronic dry mouth occurs, advise patient to:

• Avoid mouth rinses with high alcohol content because of drying effects.

• Use sugarless gum, frequent sips of water, or saliva substitutes.

• Use daily home fluoride products for anticaries effect.

lacosamide

lah-kose′-a-mide

Do not confuse with lamisil, lanoxin.

Category and Schedule

Pregnancy Risk Category: C

Drug Class:

Mechanism of Action

An anticonvulsant and antineuralgic agent whose exact mechanism is unknown but may be related to enhancement of sodium channel inactivation and modulation of collapsing response mediator protein-2 (CRMP-2). Lacosamide decreases the availability of voltage-gated sodium channels.

Uses

Adjunctive therapy of partial-onset seizures in patients 17 yr and older

Pharmacokinetics

Completely absorbed following oral administration (100%), can be taken with food. Peak plasma concentrations reached in 1–5 hr, widely distributed. Protein binding <15%. Undergoes hepatic metabolism (CYP2C19). Half-life: 13 hr. Excreted primarily by the kidneys.

Indications and Dosages

Partial-Onset Seizures

Adult.

PO 50 mg twice daily. May be increased at weekly intervals by 100 mg/day given as 2 divided doses, up to 200–400 mg/day, based on response and tolerability (intravenous form also available when oral administration not feasible).

Side Effects/AdversE Reactions

Frequent

Dizziness, diplopia, blurred vision, headache, nausea

Occasional

Abnormal vision, ataxia, fatigue, nystagmus, somnolence, tremor, vomiting

Precautions and Contraindications

Hypersensitivity to lacosamide or any of its ingredients, hepatic impairment. Safety in children not established

Drug Interactions of Concern to Dentistry

• None reported

Serious Reactions

! Hypersensitivity

Dental Considerations

General:

• Assess salivary flow as a factor in caries, periodontal disease, and candidiasis.

• Morning appointments and stress-reduction protocol may be needed for anxious patients.

• Be prepared to manage seizures and/or nausea.

• After supine positioning, allow patient to sit upright for 2 minutes to avoid occurrence of dizziness.

Consultations:

Consult with physician to determine seizure control and ability to tolerate dental procedures.

Teach Patient/Family to:

• Avoid mouth rinses with high alcohol content because of drying effect.

• Use home fluoride products for anticaries effect.

• Use sugarless/xylitol gum, frequent sips of water, or saliva substitutes if dry mouth occurs.

lamivudine

la-miv′-yoo-deen

(Epivir, Epivir-HBV, Heptovir[can], Zeffix[aus])

Do not confuse lamivudine with lamotrigine.

Category and Schedule

Pregnancy Risk Category: C

Drug Class:

Antiviral, nucleoside analogue

Mechanism of Action

An antiviral that inhibits HIV reverse transcriptase by viral DNA chain termination. Also inhibits RNA- and DNA-dependent DNA polymerase, an enzyme necessary for HIV replication.

Therapeutic Effect: Interrupts HIV replication, slowing the progression of HIV infection.

Uses

Used in combination with zidovudine for the treatment of HIV infection and to reduce disease progression and death in AIDS; HBV dose form: chronic hepatitis B associated with evidence of hepatitis B viral replication and liver inflammation

Pharmacokinetics

Rapidly and completely absorbed from the GI tract. Protein binding: less than 36%. Widely distributed (crosses the blood-brain barrier). Primarily excreted unchanged in urine. Not removed by hemodialysis or peritoneal dialysis. Half-life: 11–15 hr (intracellular), 2–11 hr (serum, adults), 1.7–2 hr (serum, children) (increased in impaired renal function).

Indications and Dosages

HIV Infection (in Combination with Other Antiretrovirals)

PO

Adults, Children 12–16 yr, weighing 50 kg (100 lb) or more.

150 mg twice a day or 300 mg once a day.

Adults weighing less than 50 kg.

2 mg/kg twice a day.

Children 3 mo–11 yr.

4 mg/kg twice a day (up to 150 mg/dose).

Chronic Hepatitis B

PO

Adults, Children 17 yr and older.

Children younger than 17 yr.

3 mg/kg/day. Maximum: 100 mg/day.

Dosage in Renal Impairment

Dosage and frequency are modified on the basis of creatinine clearance.

Creatinine Clearance	Dosage
50 ml/min or higher	150 mg twice a day
30–49 ml/min	150 mg once a day
15–29 ml/min	150 mg first dose, then
100 mg once a day	5–14 ml/min
150 mg first dose, then	50 mg once a day
Less than 5 ml/min	50 mg first dose, then 25 mg once a day

Side Effects/Adverse Reactions

Frequent

Headache, nausea, malaise and fatigue, nasal disturbances, diarrhea, cough, musculoskeletal pain, neuropathy, insomnia, anorexia, dizziness, fever or chills

Occasional

Depression, myalgia, abdominal cramps, dyspepsia, arthralgia

Precautions and Contraindications

Hypersensitivity, history of pancreatitis as child

Example: Epivir (brand name), 150 m

Caution:

Reduce dose in renal disease, lactation

Drug Interactions of Concern to Dentistry

• None reported

Serious Reactions

! Pancreatitis occurs in 13% of pediatric patients.

! Anemia, neutropenia, and thrombocytopenia occur rarely.

Dental Considerations

General:

• Patients on chronic drug therapy may rarely have symptoms of blood dyscrasias, which can include infection, bleeding, and poor healing.

• Examine for oral manifestation of opportunistic infections.

Consultations:

• In a patient with symptoms of blood dyscrasias, request a medical consultation for blood studies and postpone dental treatment until normal values are reestablished.

• Medical consultation may be required to assess disease control and patient’s ability to tolerate stress.

Teach Patient/Family to:

• Encourage effective oral hygiene to prevent soft tissue inflammation.

• Use caution to prevent trauma when using oral hygiene aids.

• See dentist immediately if secondary oral infection occurs.

lamotrigine

la-moe′-trih-jeen

(Apo-Lamotrigine[can], Lamictal, Lamictal CD)

Do not confuse lamotrigine with lamivudine.

Category and Schedule

Pregnancy Risk Category: C

Drug Class:

Mechanism of Action

An anticonvulsant whose exact mechanism is unknown. May block voltage-gated sodium channels, thus stabilizing neuronal membranes and regulating presynaptic transmitter release of excitatory amino acids.

Therapeutic Effect: Reduces seizure activity.

Uses

Adjunctive treatment of refractive partial seizures in adults and adjunctive treatment for Lennox-Gastaut syndrome in pediatric and adult patients; long-term maintenance of bipolar 1 disorder

Pharmacokinetics

Rapidly absorbed from the GI tract. Protein binding: 55%. Metabolized primarily by glucuronic acid conjugation. Excreted in the urine. Half-life: 13–30 hr.

Indications and Dosages

Seizure Control in Patients Receiving Enzyme-Inducing Antiepileptic Drug (EIAEDS), But Not Valproic Acid

PO

Adults, Elderly, Children older than 12 yr.

Recommended as add-on therapy: 50 mg once a day for 2 wk, followed by 100 mg/day in 2 divided doses for 2 wk. Maintenance: Dosage may be increased by 100 mg/day every wk, up to 300–500 mg/day in 2 divided doses.

Example: Lamotrigine (generic name), 100 mg

Children 2–12 yr.

0.6 mg/kg/day in 2 divided doses for 2 wk, then 1.2 mg/kg/day in 2 divided doses for wk 3 and 4. Maintenance: 5–15 mg/kg/day. Maximum: 400 mg/day.

Seizure Control in Patients Receiving Combination Therapy of EIAEDS and Valproic Acid

PO

Adults, Elderly, Children older than 12 yr.

25 mg every other day for 2 wk, followed by 25 mg once a day for 2 wk. Maintenance: Dosage may be increased by 25–50 mg/day q1–2wk, up to 150 mg/day in 2 divided doses.

Children 2–12 yr.

0.15 mg/kg/day in 2 divided doses for 2 wk, then 0.3 mg/kg/day in 2 divided doses for wk 3 and 4. Maintenance: 1–5 mg/kg/day in 2 divided doses. Maximum: 200 mg/day.

Conversion to Monotherapy for Patients Receiving EIAED

PO

Adults, Elderly, Children 16 yr and older.

500 mg/day in 2 divided doses. Titrate to desired dose while maintaining EIAED at fixed level, then withdraw EIAED by 20% each week over a 4-wk period.

Conversion to Monotherapy for Patients Receiving Valproic Acid

PO

Adults, Elderly, Children 16 yr and older.

Titrate lamotrigine to 200 mg/day, maintaining valproic acid dose. Maintain lamotrigine dose and decrease valproic acid to 500 mg/day, no greater than 500 mg/day/wk, then maintain 500 mg/day for 1 wk. Increase lamotrigine to 300 mg/day and decrease valproic acid to 250 mg/day. Maintain for 1 wk, then discontinue valproic acid and increase lamotrigine by 100 mg/day each wk until maintenance dose of 500 mg/day reached.

Bipolar Disorder in Patients Receiving EIAED

PO

Adults, Elderly.

50 mg/day for 2 wk, then 100 mg/day for 2 wk, then 200 mg/day for 1 wk, then 300 mg/day for 1 wk, then up to usual maintenance dose 400 mg/day in divided doses.

Bipolar Disorder in Patients Receiving Valproic Acid

PO

Adults, Elderly.

25 mg/day every other day for 2 wk, then 25 mg/day for 2 wk, then 50 mg/day for 1 wk, then 100 mg/day. Usual maintenance dose with valproic acid: 100 mg/day.

Discontinuation Therapy

Adults, Children older than 12 yr.

A dosage reduction of approximately 50% per week over at least 2 wk is recommended.

Side Effects/Adverse Reactions

Frequent

Dizziness, diplopia, headache, ataxia, nausea, blurred vision, somnolence, rhinitis, dry mouth, halitosis

Occasional

Rash, pharyngitis, vomiting, cough, flu-like symptoms, diarrhea, dysmenorrhea, fever, insomnia, dyspepsia

Rare

Constipation, tremors, anxiety, pruritus, vaginitis, hypersensitivity reaction

Precautions and Contraindications

Hypersensitivity

Caution:

Elderly, children younger than 16 yr, dose adjustment with other anticonvulsants, seizure risk with drug withdrawal, renal or hepatic impairment; can cause Stevens-Johnson syndrome, toxic epidermal necrolysis

Drug Interactions of Concern to Dentistry

• Increased excretion: chronic, high-dose acetaminophen, but significance is unclear

• Increased blood levels of carbamazepine

Serious Reactions

! Abrupt withdrawal may increase seizure frequency.

! Serious rashes, including Stevens-Johnson syndrome, requiring hospitalization and discontinuation of treatment have been reported.

Dental Considerations

General:

• Morning appointments and a stress-reduction protocol may be required for anxious patients.

• Determine type of epilepsy, seizure frequency, and quality of seizure control.

• Evaluate respiration characteristics and rate.

• Assess salivary flow as factor in caries, periodontal disease, and candidiasis.

• Patients on chronic drug therapy may rarely have symptoms of blood dyscrasias, which can include infection, bleeding, and poor healing.

• Place on frequent recall because of oral side effects.

Consultations:

• Medical consultation may be required to assess disease control and the patient’s ability to tolerate stress.

• In a patient with symptoms of blood dyscrasias, request a medical consultation for blood studies and postpone dental treatment until normal values are reestablished.

Teach Patient/Family to:

• Encourage effective oral hygiene to prevent soft tissue inflammation.

• Use powered tooth brush if patient has difficulty holding conventional devices.

• When chronic dry mouth occurs, advise patient to:

• Avoid mouth rinses with high alcohol content because of drying effects.

• Use daily home fluoride products for anticaries effect.

• Use sugarless gum, frequent sips of water, or saliva substitutes.

lanreotide

lan-ree′-oh-tide

(Somatuline Depot)

Category and Schedule

Pregnancy Risk Category: C

Drug Class:

Mechanism of Action

Octapeptide somatostatin analog that inhibits insulin-like growth factor-1 (IGF-1) and growth hormone. High affinity for somatostatin type 2 (SSTR2) and 5 (SSTR5) receptors in pituitary gland, pancreas, and growth hormone (GH) secreting neoplasms of pituitary gland. Lesser affinity for somatostatin receptors 1, 3, and 4 (SSTR1, SSTR3 and SSTR4).

Uses

Acromegaly (long-term therapy in patients who have had inadequate response to surgery and/or radiotherapy; or when surgery and/or radiotherapy is not an option)

For long-term treatment of acromegaly in patients who fail to respond to surgery and radiotherapy.

Pharmacokinetics

Protein binding: 79%–83%. Extensive metabolism in GI tract after biliary excretion. Bioavailability: 69%–83%. Less than 5% of lanreotide excreted in urine; less than 0.5% recovered unchanged in feces, indicative of some biliary excretion. Half-life: 23–36 days.

Indications and Dosages

SC Injection

Adult.

Acromegaly: 90 mg deep SC injection every 4 wk for 3 months. After 3 months adjust dose based on clinical response:

GH >1 to = 2.5 ng/mL, IGF-1 normal and clinical symptoms controlled: maintain dose at 90 mg every 4 wk

GH > 2.5 ng/mL, IGF-1 elevated and/or clinical symptoms uncontrolled, increase dose to 120 mg every 4 wk

GH = 1 ng/mL, IGF-1 normal and clinical symptoms controlled: reduce dose to 60 mg every 4 wk

Dose Adjustments

Renal impairment: 60 mg deep SC injection every 4 wk.

Hepatic impairment: 60 mg deep SC injection every 4 wk.

Geriatric: no dosage adjustment necessary.

Pediatric: Safety and effectiveness in pediatric patients have not been established.

Side Effects/Adverse Reactions

Frequent

Injection site reaction, abdominal pain, diarrhea, nausea, bradycardia, and cholelithiasis

Precautions and Contraindications

There are no contraindications listed in the manufacturer’s labeling.

Use caution in patients with cardiac disease, diabetes mellitus, gallbladder disease, hypothyroidism, renal impairment, and hepatic impairment.

Drug Interactions of Concern to Dentistry

• None reported

Serious Reactions

! Bradycardia, hypo- and hyperglycemia, gallstones, decreases in thyroid function, renal impairment, and hepatic impairment have occurred.

Dental Considerations

General:

• Patient may need assistance in getting into and out of dental chair.

• Adjust chair position for patient comfort.

• Consider semisupine chair position for patient comfort if GI side effects occur.

Consultations:

• Medical consultation may be required to assess disease control and patient’s ability to tolerate stress.

• Consultation with physician may be necessary if sedation or general anesthesia is required.

Teach Patient/Family to:

• Update health and medication history if physician makes any changes in evaluation or drug regimens; include OTC, herbal, and nonherbal remedies in the update.

• Use effective oral hygiene to prevent soft tissue inflammation.

• Use caution to prevent injury when using oral hygiene aids.

lansoprazole

lan-soe′-pra-zole

(Prevacid, Prevacid IV, Prevacid Solu-Tab, Zoton[aus])

Do not confuse Prevacid with Pepcid, Pravachol, or Prevpac.

Category and Schedule

Pregnancy Risk Category: B

Drug Class:

Antisecretory, proton pump inhibitor

Mechanism of Action

A proton pump inhibitor that selectively inhibits the parietal cell membrane enzyme system (hydrogen-potassium adenosine triphosphatase) or proton pump.

Therapeutic Effect: Suppresses gastric acid secretion.

Uses

Short-term treatment for healing and symptomatic relief of active duodenal ulcer and benign gastric ulcer, erosive esophagitis, and gastroesophageal reflux disease (GERD); maintenance of healing of duodenal ulcers; long-term treatment of pathologic hypersecretory syndromes; NSAID-associated gastric ulcers in patients who continue NSAID use; short-term treatment of symptomatic GERD

Pharmacokinetics

Rapid and complete absorption (food may decrease absorption) once drug has left stomach. Protein binding: 97%. Distributed primarily to gastric parietal cells and converted to two active metabolites. Extensively metabolized in the liver. Eliminated in bile and urine. Not removed by hemodialysis. Half-life: 1.5 hr (increased in the elderly and in those with hepatic impairment).

Indications and Dosages

Duodenal Ulcer

PO

Adults, Elderly.

15 mg/day, before eating, preferably in the morning, for up to 4 wk.

Erosive Esophagitis

PO

Adults, Elderly.

30 mg/day, before eating, for up to 8 wk. If healing does not occur within 8 wk (in 5%–10% of cases), may give for additional 8 wk. Maintenance: 15 mg/day.

IV

Adults, Elderly.

30 mg once a day for up to 7 days. Switch to oral lansoprazole therapy as soon as patient can tolerate oral route.

Gastric Ulcer

PO

Adults.

30 mg/day for up to 8 wk.

NSAID Gastric Ulcer

PO

Adults, Elderly.

(Healing): 30 mg/day for up to 8 wk. (Prevention): 15 mg/day for up to 12 wk.

Example: Prevacid (brand name), 30 mg

Healed Duodenal Ulcer, GERD

PO

Adults.

Usual Pediatric Dosage

Children 3 mo–14 yr, weighing more than 20 kg.

30 mg once daily.

Children 3 mo–14 yr, weighing 10–20 kg.

15 mg once daily.

Children 3 mo–14 yr, weighing less than 10 kg.

7.5 mg once daily.

Helicobacter pylori Infection

PO

Adults.

30 mg twice a day for 10 days (with amoxicillin and clarithromycin).

Pathologic Hypersecretory Conditions (Including Zollinger-Ellison Syndrome)

PO

Adults, Elderly.

60 mg/day. Individualize dosage according to patient needs and for as long as clinically indicated. Administer up to 120 mg/day in divided doses.

Side Effects/Adverse Reactions

Occasional

Diarrhea, abdominal pain, rash, pruritus, altered appetite

Rare

Nausea, headache

Precautions and Contraindications

Hypersensitivity

Caution:

Children younger than 18 yr, elderly (limit doses to 30 mg/day), severe hepatic disease

Drug Interactions of Concern to Dentistry

• Drug interactions not established but potentially can interfere with absorption of amoxicillin, ketoconazole

Serious Reactions

! Bilirubinemia, eosinophilia, and hyperlipemia occur rarely.

Dental Considerations

General:

• Consider semisupine chair position for patient comfort because of GI effects of disease.

• Question the patient about tolerance of NSAIDs or aspirin related to GI problem.

• Patients with GERD may have oral symptoms, including burning mouth, secondary candidiasis, and oral signs of dental erosion.

• Assess salivary flow as factor in caries, periodontal disease, and candidiasis.

Teach Patient/Family to:

• When chronic dry mouth occurs, advise patient to:

• Avoid mouth rinses with high alcohol content because of drying effects.

• Use daily home fluoride products for anticaries effect.

• Use sugarless gum, frequent sips of water, or saliva substitutes.

lanthanum carbonate

lan′-tha-num kar′-boh-nate

Category and Schedule

Pregnancy Risk Category: C

Drug Class:

Phosphate binder

Mechanism of Action

A phosphate regulator that dissociates in the acidic environment of the upper GI tract to lanthanum ions, which bind to dietary phosphate released from food during digestion, forming highly insoluble lanthanum phosphate complexes.

Example: Fosrenol (brand name), 1000 mg

Therapeutic Effect: Reduces phosphate absorption.

Uses

Treatment of end-stage renal disease

Pharmacokinetics

Phosphate complexes are eliminated in feces.

Indications and Dosages

Reduce Serum Phosphate in End-Stage Renal Disease

PO

Adults, Elderly.

750–1500 mg in divided doses, taken with or immediately after a meal. Dosage may be titrated in 750-mg increments q2–3wk on the basis of serum phosphate levels.

Side Effects/Adverse Reactions

Frequent

Nausea, vomiting, dialysis graft occlusion, abdominal pain

Precautions and Contraindications

Drug Interactions of Concern to Dentistry

• None reported

Serious Reactions

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Tags: Mosbys Dental Drug Reference 11e

Jan 5, 2015 | Posted by mrzezo in General Dentistry | Comments Off

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