[Annie59]

I have oral surgery on 3 teeth scheduled for Oct 13th. Do Any of you have experience with what docs do when they expect you to not eat or have fluids before surgery. He told me 6 hours for this one. My eye surgery was longer for cataract and the other will be be coming up in a few months.

He asked what made me worse so I said activity and heat. He asked if stress did. I said I am stronger in the earlier part of the day. So his thought was to do mid morning. Over the weekend I realized that I'd have to eat and drink by 3am if I was gonna get any. That wouldnt allow much of a good nites sleep. And then I realized how am I gonna get a good dose of mestinon in me if I cant eat! If I dont have food in my stomach I get diareah and cramping and once even vomited when I took a larger dose for a before and after mestinon test for my pulmonologist.

I asked my neuro to order an injection of prostigmine for my surgery but she blew it off. I might beable to get my pulmo to get her to do it. She has no sense of how severe my symptoms are. I know docs need some sort of perspective but she is intensely detached from pateints.

My only thought as I write this if I cant get the injection is to have the surgery in the afternoon so I can get the meds and such in me before the surgery.

Annie59

[mrsD]

When my son had his 4 wisdom teeth out, he was allowed light food with no long fast. His oral surgeon said the low blood sugar interfered with anesthetics. If you took the Mestinon with a small bit of water, at least 2 hrs before the surgery, it would be out of your stomach by the time you went to the surgeon.

The fast is so you will not vomit and aspirate stomach contents.
So the dentist should be able to give you a modified list of what to do to control your MG.

[Annie59]

Sorry I guess I wasnt clear. I absolutely cant take mestinon without food. That is what I was getting at but with more than usual brain mush lately I can be quite unlcear. My stomach and bowels have zero tolerance for mestinon now at normal doses which is one of reasons I tried prostigmin. That is also why I limp by on much smaller doses leaving me homebound from this level of weakness. When I was tolerating it better the first year and took 75mg 3 times a day I was walking great!! Now I take tiny doses but it still raises heck with my insides as if it was 60mg or more. I could vomit anyway from mestinon without food.

My teeth have been very destroyed by my sjogrens so he is gonna have to do digging beyond normal so he wants to give me IV sedation not just local. It is gonna be rough.

Annie59

Originally Posted by mrsD

When my son had his 4 wisdom teeth out, he was allowed light food with no long fast. His oral surgeon said the low blood sugar interfered with anesthetics. If you took the Mestinon with a small bit of water, at least 2 hrs before the surgery, it would be out of your stomach by the time you went to the surgeon.

The fast is so you will not vomit and aspirate stomach contents.
So the dentist should be able to give you a modified list of what to do to control your MG.

[AnnieB3]

Annie, I think that speaking to your regular doctor first is absolutely essential in this case. If you can't do without Mestinon, then you need to figure out something you can do. It doesn't really matter if you get Mestinon via the mouth or injection because if it upsets your stomach, it's more than likely due to an increased amount of stomach acid due to the increased amount of acetylcholine. Another option is Mestinon syrup, which your neuro can give you a small prescription of (like one bottle).

Anesthetic agents can make MG much worse. Pedatric gas is sometimes used instead, because it wears off more quickly and may cause less muscle weakness.

I honestly think you need to discuss this again and talk about doing it in a hospital setting.

Annie

[Annie59]

AnnieB3, Pediatric gas! That sounds like a creative idea. Yes I plan on calling my pulmonologist tomorrow. For reasons I dont understand they wont do it in my local hospital. But I think something is being withheld from me at the first oral surgeon I saw that said he do it. The one at my dentists office was too scared about my breathing and sent me to the second guy. The second guy wasnt gonns do iv sedation only local to be safe. I delayed the surgery to let the myositis in the area of my left heal. When I called back there was a 'mood' change.

I called the only other higher level oral surgeon in town and asked if they would consider doing it. I asked if I could email them a brief health bio. I told him it was very important for me to have it here in town. When the other surgeon said no he said I needed to go the univeristy where I am treated. I asked what had changed in the month since we last talked and I was scheduled? He wasnt forth coming so I let it go. The univeristy hospital is 45plus miles away causing which ever daughter takes me to lose a whole days work often for appointments. My oldeest had born the brunt of this as my youngest has too scared mom is gonna die so she has been in denial. She is moving back into helping taking me to the surgeon Friday and plans to follow thru with this tooth thing. My oldest starts a new job this week so taking me as much even in a family freiendly environment is not a good idea.

The other nite I woke with a ton of fear about this new surgeon. See I was in unusually good shape Friday. They didnt take my bp or check my O2 like the other offices. He is a young one but he did graduate from the very university my MG docs are at. I gave him the last visit report from when I saw my pulmonologist. My pulmo is a teddy bear but a big shot too at the university. I told him to feel free to call him.

Question? are you suggesting that an injection would do the same thing to my stomach and bowels? Wasnt sure about that part of your answer. The prostigmin didnt both them but only a very slight urge to go to the bathroom. At such a normal dose this even surprised me! Thats why I wish I could be on the stuff by injection in part.

Annie59

Originally Posted by AnnieB3

Annie, I think that speaking to your regular doctor first is absolutely essential in this case. If you can't do without Mestinon, then you need to figure out something you can do. It doesn't really matter if you get Mestinon via the mouth or injection because if it upsets your stomach, it's more than likely due to an increased amount of stomach acid due to the increased amount of acetylcholine. Another option is Mestinon syrup, which your neuro can give you a small prescription of (like one bottle).

Anesthetic agents can make MG much worse. Pedatric gas is sometimes used instead, because it wears off more quickly and may cause less muscle weakness.

I honestly think you need to discuss this again and talk about doing it in a hospital setting.

Annie

[mrsD]

I would wonder if the oral forms are exerting a local effect on the GI tract while they are being absorbed?

Injection also by passes the GI tract and liver, allowing for no first pass metabolism.

Neostigmine is used to reverse ileus of the bowel, so it does depending on dose affect motility. It may be the injection you are using is a low dose, compared to others.

http://www.rxlist.com/prostigmin-drug.htm

Neostigmine bromide is poorly absorbed from the gastrointestinal tract following oral administration. As a rule, 15 mg of neostigmine bromide orally is equivalent to 0.5 mg of neostigmine methylsulfate parenterally, due to poor absorption of the tablet from the intestinal tract. In a study in fasting myasthenic patients, the extent of absorption was estimated to be 1 to 2 percent of the ingested 30 mg single oral dose. Peak concentrations in plasma occurred 1 to 2 hours following drug ingestion, with considerable individual variations. The half-life ranged from 42 to 60 minutes with a mean half-life of 52 minutes.

I could not find an exact statement about absorption for PYRIDOstigme (Mestinon), but I did find this paper, which suggests pyridostigmine is eliminated a bit slower than neostigmine.
http://www.ncbi.nlm.nih.gov/pubmed/8845827

None of these agents have a high profile of GI absorption though.

[Annie59]

MrsD, This is some really good info. It made me wonder what would happen in comparison if I was given mestinon by IV. What I do know is that part of the problem I am having with mestinon now is that my nervous system is reacting differently to it. Any small response I had back in 08 when I was first put on the generic version at 60mg doses is magnified many times over.

My nervous system gets out of wack to varying degrees around my vitamin D deficiency-hyperparathyroid illness. I was an entirely different person before I was diagnosed. It is gonna be warmer than usual here this week for fall and I plan to get out in the sun 2 hopefully 3 days. I do this not just because I know how I well I will sleep, how intensely quiet and calm my body will become but also that it lowers my pain and will get the myositis im my face healing again. I am nervous and edgy when it is low as if alot of strong coffee is always in me. Adding the mestinon which has an impact on the nervous system to some degree is for me an issue. I am sure that those that dont have this medical issue this doesnt happen. ( I would place the study in here that shows in mice when given mestinon they startle easier but cant right now. If anyone is interested I will try to dig it up).

Annie59this is me on alot of mestinon with low vit D

Originally Posted by mrsD

I would wonder if the oral forms are exerting a local effect on the GI tract while they are being absorbed?

Injection also by passes the GI tract and liver, allowing for no first pass metabolism.

Neostigmine is used to reverse ileus of the bowel, so it does depending on dose affect motility. It may be the injection you are using is a low dose, compared to others.

http://www.rxlist.com/prostigmin-drug.htm


I could not find an exact statement about absorption for PYRIDOstigme (Mestinon), but I did find this paper, which suggests pyridostigmine is eliminated a bit slower than neostigmine.
http://www.ncbi.nlm.nih.gov/pubmed/8845827

None of these agents have a high profile of GI absorption though.

[mrsD]

This article illustrates blood brain permeability of PYRIDOstigmine:

http://www.nature.com/nm/journal/v2/...1296-1382.html

Normally this drug does not cross the BBB...but people do have issues, which may allow some drugs and other substances to cross. The channels in the BBB are called Zonulin channels and are also in the GI tract. They are little holes, which open and close.

Older patients tend to have more permeable BBB's. Some drugs that do not cross when younger will cross in the elderly giving central side effects. The H2 antagonists are one class that do this. Zantac and Pepcid. It is not unusual that elderly on IV Tagamet/or Zantac hallucinate on these drugs.

This article states that neostigmine also does not cross.
http://en.wikipedia.org/wiki/Neostigmine

There have been many many discussions on Parkinson's here about the blood brain barrier and permeability. If your do a search there you will find some very interesting articles with scientific citations.