immunosuppressive/immuno- modulatory therapies in oral ... · interest in relation to this...
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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
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Statement of Disclosure
I have no actual or potential conflict of interest in relation to this presentation
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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
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Symptomatic conditions• Aphthous ulcers• Gingivostomatitis (e.g. HSV)• Lichenoid mucositis• GVHD• Erosive lichen planus• Pemphigus• Pemphigoid• Erythema multiforme• Lupus/SLE
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Must have confirmation by biopsy!!
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Pharmacologic agents• Glucocorticoids• Tacrolimus• Thalidomide• Hydroxychloroquine
• Azathioprine• Penicillamine• Sulfasalazine• Turmeric paste
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Van Dyke TE, Serhan CN. A novel approach to resolving inflammation. 2006 Sci Am Oral and Whole Body
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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)
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Systemic effects of therapy• CNS• Bleeding• Stomach ulcers• CV• Respiratory• Endocrine disorders• MRONJ• Interactions with other Rxs
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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
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Glucocorticoids• Prednisone, dexamethasone,
clobetasol, fluocinonide…
• Suppression of cell mediators– Chemotaxis– Capillary permeability
• Fibroblasts, osteocytes delayed, atrophy
• Fat distribution altered2017 Wendy S. Hupp, DMD
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Steroids…
• HF, HTN• “Dreams” and euphoria; suicidal
behavior• Urticaria and erythema• Cushing’s syndrome, DM• PUD• Muscle wasting• And others…
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Tacrolimus (calcineurininhibitor)
• Can by used topically or systemically
• Acute renal failure• MI• Ulcers• Myalgia• Neuropathy
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Thalidomide (angiogenesis inhibitor, antineoplastic agent)
• Bone marrow suppression– Anemia– Thrombocytopenia
• VTE• HF/edema• Peripheral neuropathy
• ***Birth defects***2017 Wendy S. Hupp, DMD
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Hydroxychloroquine (antimalarial)
• Also considered DMARD for SLE and RA
• Retinal toxicity• Hypoglycemia (can be life-threatening)• Reduced PMN and complement
function• thrombocytopenia
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Other Rxs
• Penicillamine, pentoxifylline, azathioprine, sulfasalazine, dapsone, levamisole
• Herbals: curcumin (turmeric) paste– Was it really in there?– What else is in there?– thrombocytopathy
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