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