Drug use in OM

Question 1

When is non-steroidal topical therapy used in OM?

Answer 1

For inconvenient lesions causing discomfort

Question 2

When is steroidal topical therapy used in OM?

Answer 2

For disabling immunologically driven lesions

Question 3

What are examples of non-steroidal treatments for oral lesions?

Answer 3

CHX

Benzdamine Mouthwash

OTC remedies- bonjela, igloo, listerine, aloe vera
-> or anything patient believes to help

Question 4

In what situations is CHX deemed beneficial for oral mucosal lesions?

Answer 4

For managing oral mucosal infections and conditions where secondary infections can occur

Question 5

What instructions/warnings should be discussed with patient regarding use of CHX?

Answer 5

 Dilute- if taste not liked
 Staining can occur- if following use of mouthwash with food containing pigments (use last thing at night)
 Ask about allergy

Question 6

What is benzdamine and its use?

Answer 6

Essentially an NSAID
 Analgesic relief to painful mucosal conditions
 Green coloured things are psychologically more beneficial
 Can be used before meal-times

Question 7

What should be done if OTC remedies are being used frequently for oral mucosal lesions?

Answer 7

Consider a prescripted preparation

Question 8

What steroid based treatments can be used for oral mucosal lesions? (not available OTC)

Answer 8

Hydrocortisone mucoadhesive pellet

Betamethasone mouthwash*

Beclomethasone Metered Dose Inhaler* (MDI/Puffer)

*unlicensed

Question 9

How are mucoadhesive pellets used?

Answer 9

Applied to area of ulceration, allowed to dissolve and adheres as it becomes a gel
 Treats lesion and gives physical protection too

Question 10

Why does hydrocortisone have to be applied in a way that allows more contact?

Answer 10

Less potent than beta/beclamethasone (which are of a higher but equal potency)

Question 11

How is a betamethasone mouthwash prepared?

Answer 11

2 betnesol tablets (0.5mg each) are dissolved in 10ml of water

Question 12

How is betamethasone mouthwash used?
(provide tailored PIL)

Answer 12

2 mins rinsing

Twice daily

Refrain from eating/drinking for 30 min after use

DO NOT SWALLOW- prevents unwanted systemic effects

Do not rinse after use

Question 13

What are the ADV of betamethasone mouthwash?

Answer 13

Flexible- can be made more concentrated/less concentrated, frequency can be changed too

Good for widespread lesions

Question 14

What additional info should be included in PIL for betamethasone mouthwash?

Answer 14

Licensed for other medical conditions
above 12 years of age
-> Use with caution below this age

Explain hazards of exceeding the standard dose

Safe to use as directed without standard steroid side effects risk – diabetes, osteoporosis, adrenal suppression, etc

No Steroid card needed if used properly

Known side effects – small oral candida risk

Question 15

How is a beclomethasone MDI used?

Answer 15

Use 50mcg/puff device:
Position device correctly – exit vent directly over ulcer area
2 puffs
2-4 times daily
Don’t rinse after use!

Question 16

Which devices should never be used when administering beclamethasone for oral mucosal lesions?

Answer 16

Breath-activated devices (turbo/spinhaler)
-> do not deposit powder as required for therapeutic benefit

Question 17

What are the known side effects for use of beclamethasone as a drug in OM?

Answer 17

Small candida risk

Question 18

What is an example of a disease modulating drug?

Answer 18

Colchicine

Question 19

Which oral steroid can be used in OM?

Answer 19

Prednisolone

Question 20

Why is prednisolone used in OM? What is the frequency allowed?

Answer 20

Can be pulsed for intermittent troublesome ulcers

High dose/short duration 30mg for 5 days

Need to ensure not used too frequently – once each month, must be at least 2 week gaps
-> should not be used long term

Question 21

What are the side effects of long term prednisolone use?

Answer 21

Adrenal suppression (steroid dependency)
-> don’t stop suddenly – taper dose

Cushingoid features

Osteoporosis risk – bone prophylaxis
-> Calcium supps and bisphosphonates
-> DEXA bone density scan may be needed from time to time

Peptic ulcer risk – Proton Pump Inhibitor prophylaxis

Mood/Sleep alteration

Mania/depression risk – can be very quick onset

Question 22

Which immunosuppressants may be used in OM?

Answer 22

Hydroxychloroquine – mainly for Lichen Planus

Azathioprine

Mycophenolate

Question 23

What are aza/myco normally used for?

Answer 23

Transplants- help prevent rejection

Question 24

What should be done when putting patient on immune-altering therapy?

Answer 24

Warn about infection risks, cancer risks, adverse drug reactions

Always communicate proposed treatment to the GP – may be medical issues about which the OM clinician is unaware

Question 25

Which practitioners can prescribe immune-modulating drugs for oral mucosal lesions

Answer 25

Specialists only

Question 26

What cancer is azathioprine use a risk factor for?

Answer 26

Skin

Question 27

Which medical checks should be carried out prior to a patient beginning use of an immunomodulatory drug?

Answer 27

Blood borne virus screen- Hep B, Hep C, HIV

FBC

Electrolytes

Liver Function tests

Thiopurine Methyltransferase (TPMT)- only for Azathioprine use

Zoster antibody screen

EBV

Chest X-Ray- evidence of previous/active TB (as this can reactivate)

Cervical Smear test

Pregnancy test

Question 28

When is immunomodulatory treatment considered for oral mucosal lesions?

Answer 28

Only once alternative treatments have been tried or discussed

-> full consent required, discuss over multiple visits

Question 29

What is the issue regarding pregnancy and use of immunomodualtory drugs?

Answer 29

Patient must be on effective contraception while recieving this therapy

-> pregnancy should be planned with care team

Question 30

How is treatment using immunomodulatory therapy carried out?

Answer 30

Initially there is a 6 month trial period- then risks and benefits are evaluated

Question 31

Which treatment outcomes must be discussed with patient before they start with immunomodulatory therapy?

Answer 31

Remission can occur

That an acceptable level of disease may be a good outcome