Answer to Foster Brooks Case

Vahn Lewis, Dental Pharmacology UTDB

The first clue in the Foster Brooks case is in the address. Your patients may not live on Skidrowski Avenue but from the history you may be able to tell that your patient is down and out. Alcoholics may also be pillars of the community, however the medical consequences of the disease are perhaps more apparent in the down and out patient.

From the patients age and weight you know that he is older which means that he would tend to have decreased liver and kidney function and he is also small (average adult weight=150 lb.)

Your patient presents with an infection which you will want to treat. The prognosis for treatment, which may be related to his social status and perhaps malnutrition, is not as good as for a non-alcoholic patient. Alcoholics can consume a large number of calories as ethanol and can become vitamin deficient. In a vitamin deficient state he would have decreased resistance to infection and a poorer prognosis for healing (recovery).

He is in great pain. You may want to treat his pain. Caution will be required here. His pain may be organic (that is of pathologic origin), it may be manipulative, i.e. he wants you to give him a psychoactive drug to treat it (i.e. polydrug abuse). His pain may be modified by his current drinking status. Alcohol is a weak analgesic, however, if he is in withdrawal he may be hyper-expressive of his pain.

Medical history: He has a 20 year history of excessive alcohol consumption. The effect of alcohol on metabolism can move in different directions. When young people are alcoholics they tend to have induced (or increase) hepatic microsomal enzyme function and can metabolize many drugs FASTER than others. However, after prolonged drinking, with the development of fatty liver or cirrhosis of the liver, as in this patient, there will be reduced drug metabolizing ability. This is another factor that suggests that for any drugs cleared by the liver, the amount that you administer should be reduced.

The liver also produces plasma proteins. Many drugs bind to the plasma proteins and the plasma free drug depends on a relatively normal complement of plasma proteins. This can effect the clearance of the drug and its duration of action.

This patient has a history of stomach ulcers. Alcoholics often have gastritis and/or pancreatitis. Your patient is taking cimetadine, a H2 histamine receptor blocker used to treat ulcers. Cimetadine has a side effect of inhibiting the drug metabolizing enzymes of the liver (another reason to decrease the dose of any drugs primarily metabolized by the liver). Another consequence of this patient's ulcers is that you should avoid drugs which can irritate or cause bleeding of his stomach. Many of the aspirin like NSAID can reduce the protective mucous layer of the stomach and increased the likelihood of bleeding. In addition, many of these drugs also can block platelet aggregation which can increase the consequences of bleeding. Patients with liver disorders may have reduced prothrombin.

Summary: This patient has many factors which suggest that he will be easily overdosed with drugs that are metabolized in the liver (such as opiates, acetaminophen and the antibiotics erythromycin, clindamycin and tetracycline) or are bound extensively to plasma proteins. He is also going to be sensitive to agents that can induce ulcers (such as the NSAIDs). He is likely to be difficult to treat with antibiotics because he is likely to have reduce immune competency and reduced healing ability .

Treatment: Try to avoid jumping to drugs that you know less about. Treating with exotic agents will produce more surprises and you will be less able to handle the responses.   A better approach would be to try to adjust doses of the drugs you commonly work with and then monitor the results to see how the patient responds.

Most of the penicillin type antibiotics are primarily cleared by the kidney. Remember that alcohol may increase urine output and thereby increase the loss of the drug.   Penicillin VK has a wide therapeutic margin so there will be some latitude for dosing. Since this patient may be somewhat immuno-compromised, try to use bateriocidal drugs in full dose.  Penicillin VK 500 mg would be appropriate. Greater care would need to be employed if the patient were allergic to the "cillins". Many of the other antibiotics are extensively metabolized by the liver and do not have as wide a therapeutic margin as penicillin VK. You may need to extend your course of therapy to a longer period, such as 10 days instead of 7.

Go with reduced doses of standard agents such as Tylenol #3, I tab (normal adult dose would be ii tabs) q6h (normal frequency would be q4h) if needed for pain. This would be a low dose for most patients, but could be effective in this patient. One Vicodin (not ES) could be too much (this is an educated speculation). You are less likely to overdose or have severe drug interactions with a milder agent. Remember, the lower doses are being used because these can produce therapeutic levels in this patient, we want to give effective treatment. Prescribe for small quantities if you think there is a risk that the patient will use too many. Remember: the recommendation for maximum acetaminophen dose per day in an alcoholic patient is reduced by one half (2000 mg). 

Go for conservative but effective therapy. What prescriptions did you write?

What do you tell the patient? Tell him the same things you would tell any other patient. The name of the drug, what it is for, how and when to use it and so forth. There is a great temptation to tell the patient to stop drinking any alcohol. While this sounds good, if he were foolish enough to follow your advice it would be likely to put him into a withdrawal reaction (the DT's or seizures).

Should you just skip treating him? Your other patients might appreciate it! However, recall that many famous people, at one time or another, have sunk into alcoholism. Rather than put your blinders on, do your best to give all of your patients, professional, ethical, medically and scientifically optimum care. You'll be surprised at how rewarding some of your successes will be. Don't become a victim by letting such patients take over your practice, however.

How to deal with his alcoholism. Alcoholism is not easily treated. It is a disease of denial. Drug abusers often feel that they are in control and "can stop whenever they want to". Recovery may come when some life event convinces the alcoholic that he has more to loose by continuing his habit than he has to gain. Losses include: loss of a car, loved ones, drivers license, job etc. Only when the realization that being drunk isn't cool and that continuing drinking will incur a high price, will the user be sufficiently motivated to kick his habit. The dental professional can inform the patient of the medical consequences of his dependence such as loss of health, loss of teeth, increased medical expenses (paying the dentist for treatment of preventable disease.), reduced therapeutic success and so forth. Its not his fault but it is his problem.

What drug interactions are important:

1. Alcohol

2. Early stage alcoholism

3. Late stage alcoholism