From Local anaesthesia for Dental professionals

 Modifications to Local Anesthesia for Common Medical Conditions

Condition	Local Anesthetic Considerations	Vasoconstrictor Considerations	Modifications
Diabetes	None of Significance	Epinephrine opposes the action of insulin Minute amounts used in dentistry do not raise blood levels significantly	Use epinephrine withcaution when there is significant cardiovascular disease and/or uncontrolled diabetes.
Glaucoma	None of Significance	Vasoconstrictors cause increased ocular pressure	Avoid vasoconstrictors
Hypertension	None of Significance	Vasoconstrictors can increase the risk of hypertensive episodes however the lack of profound anesthesia can increase levels ofendogenous epinephrineControversial topic	Clinical judgment and medical consult advised Note: Uncontrolled hypertensives eithershould not be treatedor treated with caution, depending upon severity See Table 10-1 ASA Physical Status Classification Blood Pressure Guidelines for Adults
Hyperthyroidism A—Controlled	None of Significance	Hyperthyroidism appears to increase tissue sensitivity to epinephrine	When there is obvious evidence of hyperthyroidism avoidepinephrine
Hyperthyroidism B—Uncontrolled	None of Significance	Risk of seriously increased tissue sensitivity to epinephrine	Avoid all treatment until condition is under control
Hypothyroidism A—Controlled	Generally Safe	Generally Safe	Hypothyroid patients tend to be sensitive to CNS depressants Local anesthetic doses should be kept to aminimum
Hypothyroidism B—Poorly Controlled with mild symptoms	Generally Safe	Generally Safe	Hypothyroid patients tend to be sensitive to CNS depressants Caution with LA drug dosing. Hypothermia, bradycardia, severe hypotension and seizures are possible.
Hypothyroidism C—Severe or Untreated	Avoid all treatment until condition is under control
Myasthenia Gravis	Esters and articaine compete for diminished supplies of acetyl choline	None of Significance	Avoid esters and articaine

Medical Predispositions That May Require Modifications

Condition	Local Anesthetic Considerations	Vasoconstrictor Considerations	Modifications
Significant Hepatic Disease	Amides are primarily metabolized in the liver	Cholinesterase is primarily manufactured in the liver although there are extra-hepatic sources	Caution with use of amides Articaine is the preferred amide but appointments should beshorter with reduced dosagesadministered If other amides are used, limit even further
Atypical Cholinesterase	Amides are not affected	None of Significance	Avoid esters & articaine
Significant Renal Dysfunction	All drugs cleared more slowly, with increased risk of overdose	All drugs cleared more slowly, with increased risk of overdose	Medical consult advised Limitdoses of all drugs depending upon severity
Methemoglobinemia	Increased risk with prilocaine and benzocaine	None of Significance	Substitute other amides for prilocaine and other topicals for benzocaine Avoid prilocaine or benzocaine when excessive doses of acetaminophen are used
Malignant Hyperthermia	local anesthetic agents safe for MH patients: articaine bupivacaine lidocaine mepivacaine prilocaine	None of Significance	Medical consult is recommended When treating these patients follow the MHAUS* guidelines
*MHAUS: Malignant Hyperthermia Association of the United States

Modifications to Local Anesthesia for Common Concomitant Drug Therapy

Medications Examples: Proprietary (generic)	Local Anesthetic Considerations	Vasoconstrictor Considerations	Modifications
Anticonvulsants Klonopin (clonazepam) Dilantin (phenytoin) Depakote (valproic acid) Topamax (topiramate)	Anxiety reduction requires effective local anesthesia. Sensitive to CNS depressants	None of Significance	Avoid higher doses of local anesthetic drugs
Antipsychotics Zyprexa (olanzapine) Seroquel (quetiapine) Risperdal (risperidone)	Increased sensitivity to CNS depressants	None of Significance	Avoid higher doses of local anesthetic drugs
Antidepressants Tricyclic Elavil (amitriptyline) Tofranil (imipramine)	None of Significance	Increases risk of hypertensive episode by opposing the reuptake of norepinephrine	Limit doses ofepinephrine(observe cardiac dose limits) Avoid levonordefrin
Antidepressants Serotonin/Norepinephrine Reuptake Inhibitor Effexor (venlafaxine) Savella (milnacipran)	None of Significance	Oppose the reuptake of norepinephrine	Suggest caution
Antidepressants Central Alpha-2 Antagonist Remeron (mirtazapine)	None of Significance	Increases release of norepinephrine	Suggest caution
Antidepressants Dopamine Reuptake Inhibitor Wellbutrin (Bupropion) Zyban (Bupropion)	None of Significance	Oppose the reuptake of norepinephrine	Suggest caution
Antidepressants Other Cymbalta (duloxetine)	None of Significance	Oppose the reuptake of norepinephrine	Suggest caution
Anxiolytics Valium (diazepam)	CNS depressant effect of local anesthetics may be additive	None of Significance	Limit dosages
Glucocorticoids Nasonex (mometasone) Entocort (budesonide) Advair (fluticasone) Aristocort (triamcinolone)	Stress associated with local anesthesia is considered to be low	Stress associated with local anesthesia is considered to be low	Considersupplemental stress reduction such as nitrous oxide or IV sedation
β-blockers Nonselective Inderal (propranolol) Corgard (nadolol) Blocadren (timolol)	With propranolol, minimal doses of lidocaine are recommended	Increased risk of hypertensive episode and reflexive bradycardia and in a few individuals, strokes	Unless vasoconstriction is necessary, limit or avoidvasoconstrictors
Histamine H2 Receptor Blockers Tagamet (cimetidine) Zantac (ranitidine)	Tagamet competes with lidocaine for liver isoenzymes Slows lidocaine metabolism increasing the risk of overdose Zantac and others do not have this effect	None of Significance	Use caution with large doses of lidocaine particularly in the presence of significant congestive heart failure
Monoamine Oxidase Inhibitors Nardil (phenelzine) Parnate (tranylcypromine) Marplan (isocarboxazid)	None of Significance	None of Significance	None
Phenothiazinesantipsychotic/antiemetic/neuroleptics Thorazine (chlorpromazine) Mellaril (thioridazine)	None of Significance	Hypotension, possibly severe, is the primary effect of epinephrine with these drugs	Observe cardiaclimit of vasoconstrictors (0.04 mg). Do not use 1:50,000epinephrine
Limited examples are provided in each category; numerous drugs may be included in these categories. Current drug indexes should be consulted for the most up-to-date information.

Illegal ("Recreational") Drug Use*

Drug	Local Anesthetic Considerations	Vasoconstrictor Considerations	Modifications
Methamphetamine	None of Significance	Administration of vasoconstrictors may result in hypertensive crisis, stroke, or myocardial infarction	Do not administer local anesthetics with vasoconstrictors for a minimum of 24 hours after methamphetamine use
Cocaine	Cocaine is a strong CNS depressant; local anesthetics compound CNS depression and administration should beavoided	Administration of vasoconstrictors significantly increases the risk of hypertensive crisis, stroke, or myocardial infarction	Do not administer local anesthetics with vasoconstrictors for a minimum of 24 hours after cocaine use
Alcohol	May decrease the effectiveness of local anesthetics	None of Significance	Use caution to avoid overdose
*If a patient is under the influence of a drug or alcohol, any informed consent taken may be invalid as the patient may not be "competent" to give consent. For all drugs not on this list, it is prudent to consult a drug index before administering all local anesthetic drugs.