Drug use in OM Flashcards
When is non-steroidal topical therapy used in OM?
For inconvenient lesions causing discomfort
When is steroidal topical therapy used in OM?
For disabling immunologically driven lesions
What are examples of non-steroidal treatments for oral lesions?
CHX
Benzdamine Mouthwash
OTC remedies- bonjela, igloo, listerine, aloe vera
-> or anything patient believes to help
In what situations is CHX deemed beneficial for oral mucosal lesions?
For managing oral mucosal infections and conditions where secondary infections can occur
What instructions/warnings should be discussed with patient regarding use of CHX?
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
What is benzdamine and its use?
Essentially an NSAID
Analgesic relief to painful mucosal conditions
Green coloured things are psychologically more beneficial
Can be used before meal-times
What should be done if OTC remedies are being used frequently for oral mucosal lesions?
Consider a prescripted preparation
What steroid based treatments can be used for oral mucosal lesions? (not available OTC)
Hydrocortisone mucoadhesive pellet
Betamethasone mouthwash*
Beclomethasone Metered Dose Inhaler* (MDI/Puffer)
*unlicensed
How are mucoadhesive pellets used?
Applied to area of ulceration, allowed to dissolve and adheres as it becomes a gel
Treats lesion and gives physical protection too
Why does hydrocortisone have to be applied in a way that allows more contact?
Less potent than beta/beclamethasone (which are of a higher but equal potency)
How is a betamethasone mouthwash prepared?
2 betnesol tablets (0.5mg each) are dissolved in 10ml of water
How is betamethasone mouthwash used?
(provide tailored PIL)
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
What are the ADV of betamethasone mouthwash?
Flexible- can be made more concentrated/less concentrated, frequency can be changed too
Good for widespread lesions
What additional info should be included in PIL for betamethasone mouthwash?
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
How is a beclomethasone MDI used?
Use 50mcg/puff device:
Position device correctly – exit vent directly over ulcer area
2 puffs
2-4 times daily
Don’t rinse after use!
Which devices should never be used when administering beclamethasone for oral mucosal lesions?
Breath-activated devices (turbo/spinhaler)
-> do not deposit powder as required for therapeutic benefit
What are the known side effects for use of beclamethasone as a drug in OM?
Small candida risk
What is an example of a disease modulating drug?
Colchicine
Which oral steroid can be used in OM?
Prednisolone
Why is prednisolone used in OM? What is the frequency allowed?
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
What are the side effects of long term prednisolone use?
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
Which immunosuppressants may be used in OM?
Hydroxychloroquine – mainly for Lichen Planus
Azathioprine
Mycophenolate
What are aza/myco normally used for?
Transplants- help prevent rejection
What should be done when putting patient on immune-altering therapy?
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
Which practitioners can prescribe immune-modulating drugs for oral mucosal lesions
Specialists only
What cancer is azathioprine use a risk factor for?
Skin
Which medical checks should be carried out prior to a patient beginning use of an immunomodulatory drug?
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
When is immunomodulatory treatment considered for oral mucosal lesions?
Only once alternative treatments have been tried or discussed
-> full consent required, discuss over multiple visits
What is the issue regarding pregnancy and use of immunomodualtory drugs?
Patient must be on effective contraception while recieving this therapy
-> pregnancy should be planned with care team
How is treatment using immunomodulatory therapy carried out?
Initially there is a 6 month trial period- then risks and benefits are evaluated
Which treatment outcomes must be discussed with patient before they start with immunomodulatory therapy?
Remission can occur
That an acceptable level of disease may be a good outcome
