immunosuppressive/immuno- modulatory therapies in oral ... · interest in relation to this...

2017 Wendy S. Hupp, DMD

Immunosuppressive/immuno-modulatory therapies in oral

medicine: Best friend and worst enemy

Wendy S. Hupp, DMDUniversity of Louisville

April 8, 20172017 Wendy S. Hupp, DMD

Statement of Disclosure

I have no actual or potential conflict of interest in relation to this presentation

2017 Wendy S. Hupp, DMD

Frenemies?

1. Principles of topical and systemic therapies

2. Overview of the evidence base supporting the use of these modalities

3. Local and systemic side effects secondary to immunosuppressive/immunomodulatory therapies

2017 Wendy S. Hupp, DMD

Symptomatic conditions• Aphthous ulcers• Gingivostomatitis (e.g. HSV)• Lichenoid mucositis• GVHD• Erosive lichen planus• Pemphigus• Pemphigoid• Erythema multiforme• Lupus/SLE

2017 Wendy S. Hupp, DMD

Must have confirmation by biopsy!!

Pharmacologic agents• Glucocorticoids• Tacrolimus• Thalidomide• Hydroxychloroquine

• Azathioprine• Penicillamine• Sulfasalazine• Turmeric paste

2017 Wendy S. Hupp, DMD

2017 Wendy S. Hupp, DMD

Van Dyke TE, Serhan CN. A novel approach to resolving inflammation. 2006 Sci Am Oral and Whole Body

Local side effects of therapy

• Candidosis• Other infections• Atrophy of tissue (or is this a systemic

problem)– Erosive esophagitis and PUD– “thinning” of tissue

• Poor wound healing (or is this a systemic problem)

2017 Wendy S. Hupp, DMD

2017 Wendy S. Hupp, DMD

2017 Wendy S. Hupp, DMD

2017 Wendy S. Hupp, DMD

Systemic effects of therapy• CNS• Bleeding• Stomach ulcers• CV• Respiratory• Endocrine disorders• MRONJ• Interactions with other Rxs

2017 Wendy S. Hupp, DMD

Systemic effects of therapy

Each group of drugs may have a range of mild to life-threatening side effects

– May be helpful to consult M.D. who is helping treat the patient

– Drug references are typically objective, i.e. EVERY side effect ever reported is listed; literature review is usually a bit more realistic

2017 Wendy S. Hupp, DMD

Glucocorticoids• Prednisone, dexamethasone,

clobetasol, fluocinonide…

• Suppression of cell mediators– Chemotaxis– Capillary permeability

• Fibroblasts, osteocytes delayed, atrophy

• Fat distribution altered2017 Wendy S. Hupp, DMD

Steroids…

• HF, HTN• “Dreams” and euphoria; suicidal

behavior• Urticaria and erythema• Cushing’s syndrome, DM• PUD• Muscle wasting• And others…

2017 Wendy S. Hupp, DMD

Tacrolimus (calcineurininhibitor)

• Can by used topically or systemically

• Acute renal failure• MI• Ulcers• Myalgia• Neuropathy

2017 Wendy S. Hupp, DMD

Thalidomide (angiogenesis inhibitor, antineoplastic agent)

• Bone marrow suppression– Anemia– Thrombocytopenia

• VTE• HF/edema• Peripheral neuropathy

• ***Birth defects***2017 Wendy S. Hupp, DMD

Hydroxychloroquine (antimalarial)

• Also considered DMARD for SLE and RA

• Retinal toxicity• Hypoglycemia (can be life-threatening)• Reduced PMN and complement

function• thrombocytopenia

2017 Wendy S. Hupp, DMD

Other Rxs

• Penicillamine, pentoxifylline, azathioprine, sulfasalazine, dapsone, levamisole

• Herbals: curcumin (turmeric) paste– Was it really in there?– What else is in there?– thrombocytopathy

2017 Wendy S. Hupp, DMD

2017 Wendy S. Hupp, DMD

2017 Wendy S. Hupp, DMD