10 - Smoking Cessation Flashcards by Karlo Sison

Low Doses of Nicotine causese what?

INCREASED

Alertness

Cognitive Function

Cholinergic agonist = ^^ BP / HR / O2 Consumption

stimulate respiratory system

relax skeletal muscle

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HIGH doses of Nicotine does what?

Stimulates “REWARD” Center in limbic system

Nicotine -> Brain -> Nicotine receptors stimulated

Ventral Tegmental Area –> Nucleus Accumbens

–> Prefrontal Cortex –> DOPAMINE RELEASE

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Physical WITHDRAWAL effects

Sweating / Cold-like Symptoms

Tingling in extremeties

Nausea + Headache

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Emotional Withdrawal effects of Nicotine

Anxiety / Irritability

Insomnia / Depression

Confusion / Difficulty concentrating

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Non-Pharmacologic Treatment for

Smoking Cessation

Education

Trigger Planning

Motivational Interviewing

THE 5 A’s

Ask / Advise / Assess / Assist / Arrange

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Pharmacologic treament for

Smoking Cessation

OTC Nicotine Replacement Therapy = NRT
Path / Gum / Lozenge

RX Medications

Buproprion SR = Zyban

Varenicline Tartrate = Chantix

Nicotine Inhaler

Nicotine Nasal Spray

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Exceptions to Smoking Cessation Therapy

Pregnant / Adolescent

Light Smoker / smokeless tobacco users

Combo of meds + counseling is more effective than just 1

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Rationale of NRT Therapy

Reduces PHYSICAL withdrawal from nicotine

Patient not exposed to carcinogens / toxic component of cigs

Use of NRT INCREASES QUIT RATES by ~2 Fold

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Nicotine Patch Facts

Nicoderm CQ

Delivery to systemic circulation, avoids hepatic FIRST PASS metabolism

ONLY LONG ACTING NRT product
QD dosing

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Nicotine Patch DOSING

_> 10 cigs per day** = **Step 1_
(_21mg for 4-6 weeks)_

*Step 2:**
*14mg for 6 weeks (2 weeks)**

Step 3:
7mg for 2 weeks

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Nicotine Patch Administration

Apply to clean / dry / hairless area of skin
on upper chest / upper arm / hip

Leave on for 16-24 hours
ROTATE admin site
if falls off or loosens, REPLACE w/ new patch

Can be left on while SHOWERING / BATHING

Do not cut patch

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Nicotine Patch

Side Effects / Education

Most common = Skin irritation / Redness ~50%
AVOID use in those with dermatologic conditions
psoriasis / eczema / atopic dermatitis

Vivid Dreams / Sleep disturbance

*Headache / Nausea**
nausea might be from TOO HIGH DOSE*

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Nicotine GUM + LOZENGE

Facts

SHORT ACTING NRT products

4mg or 2mg for both

Lozenge delivers ~25% MORE nicotine vs equivilant gum dose

Various Flavors

Absorption is pH dependent
has buffering agents

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Nicotine GUM / LOZENGE

DOSING

4mg if 1st cig smoked within <30 min after waking

2mg if not

Chew *at LEAST >*9 pieces/day for first 6 weeks

DO NOT EXCEED 24 GUM PIECES PER DAY

DO NOT EXCEED 20 LOZENGES PER DAY
or 5 Lozenges in a 6 hour period

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Nicotine GUM / LOZENGE

DOSING SCHEDULE

*Weeks 1-6**
*1 piece Q1-2h**
*Weeks 7-9**
*1 piece Q2-4h**
Weeks 10-12*
*1 piece** Q4-8h

DO NOT EXCEED _24 PIECES_ PER DAY

DO NOT EXCEED _20 LOZENGES_ PER DAY
or _5 Lozenges in a 6 hour period_

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MAX DOSING

for Nicotine GUM

DO NOT EXCEED

24 GUM PIECES

PER DAY

MAX DOSING for

Nicotine LOZENGES

DO NOT EXCEED

20 LOZENGES PER DAY
or

5 Lozenges in a 6 hour period

Chew and Park Method

for Nicotine Gum Admin

Chew slowly until you notice a PEPPER TASTE OR TINGLE

“PARK” gum into the side of mouth

When taste or tingle FADES,
chew again -> REPEAT

Repeat for 20-30 minutes

Avoid eating / drinking _15 minutes_ before/during chewing gum

Nicotine LOZENGE

Administration

1 lozenge in bowht and allow to slowly dissolve (20-30min)

do not CHEW or SWALLOW

Once in a while use tongue to move lozenge from side to side

Do not use within _15 minutes_ of eating/drinking _ACIDIC_ foods or beverages

Side Effects of

NICOTINE GUM / LOZENGES

Hiccups / Flatulence

Nausea / Heartburn / Dyspepsia

Mouth Soreness / jaw ache from gum

Gum may stick to dental work
avoid in those with _dentures_

Advantages of Nicotine GUM / LOZENGE

Might satisfy ORAL cravings

might* delay weight gain
4-mg*

Patients can titrate therapy to manage withdrawal symptoms

Nicotine INHALER

Counseling / Considerations

Menthol Flavor / Helps with hand+mouth satisfaction

caution with those w/ _reactive airway disease_
absorption is pH dependent

Cough / Rhinitis / Dyspepsia / Headache

Mild irritation of MOUTH or THROAT

relatively mild and frequency declines with use

Nicotine INHALER

Administration

Place 1 cartridge into inhaler
1. Push Top / bottom of mouthpiece back together
Puff on inhaler in short breaths
1. during inhilation nicotine is vaporized
2. absorbed across OROPHARYNGEAL MUCOSA
Nicotine is used up after about 20 minutes of puffing
1. __do not use within _15 minutes_ of eating/drinking

Nicotine INHALER

DOSING

Start with >6 Cartridges/day
during the first 3-6 weeks of therapy

Increase prn to a MAX of 16 cartridges/ day

Recommended duration is 3 months

Patients STRUGGLE to use enough cartridges

**Nicotine NASAL SPRAY** **Counseling / Considerations** **Nicotrol NS (10mg/ml)**

**Rapid Absorption** = Quick onset tilt head back to administer High potential for **abuse** *avoid in those with **_Allergic Rhinitis_*** ***_DO NOT Sniff / Swallow / Inhale_*** through nose as dose is being administered **Hot Peppery feeling** in back of throat / nose * *Sneezing / Coughing / Runny Nose / Watery Eyes** * side effects limit its use*

**Nicotine NASAL SPRAY** **DOSING** **Nicotrol NS (10mg/mL)**

Use at LEAST **_\> 8 doses/day_** for the first **_6-8 weeks_** for optimal results **1 dose = 0.5mg (1spray) in EACH nostril** *May be beneficial to **_taper over 4-6 weeks_***

**Nicotine NASAL SPRAY** **Dosing Schedule / Max Doses**

**_1-2 doses/hour_** 1 dose = 0.5mg (1 spray) in EACH nostril ## Footnote **MAX 5 doses/hour** **MAX 40 doses/day** **_3 MONTHS OF THERAPY RECOMMENDE_**

**Varenicline** **MoA / Effects**

**Chantix** Binds with HIGH affinity & selectively @ **a2b2 neuronal nicotinic acetylcholine receptors** Stimulates *low-level* agonist activity Competitively *inhibits* binding of nicotine * **_Reduce symptoms of nicotine WITHDRAWAL_*** * blocks **_dopaminergic stimulation_*** responsible for * *reinforcement / reward** associated w/ smoking

**Varenicline** **DOSING**

Patients should BEGIN THERAPY **_1 week PRIOR to quit date_** Increase dose GRADUALLY to *minimize* treatment-related **nausea / insomnia** **_Days 1 -3 : 0.5mg QD_** **Days 4-7: 0.5mg BID** ***Days 8 to end: 1mg BID*** _has RENAL dosing_

**Varenicline** **RENAL DOSING**

_**CrCl \<30 ml/min**: **0.5mg QD** --\> **MAX 0.5mg BID**_ * *Hemodialysis Dosing: 0. 5mg QD**

**Varenicline = Chantix** **SIDE EFFECTS**

**Nausea / Headache / Dry Mouth** _**Insomnia** **+ Abnormal Dreams**_ **Constipation** **Suicide / Aggresiveness / Mood Changes**

**Bupropion** **MoA / Effects**

* *ZYBAN** * *_Atypical antidepressant_** thought to affect levels of: * *Dopamine + Norepinephrine** Beneficial for **_Patients concerned with WEIGHT GAIN_** helpful in patients with **underlying depression**, *may increase anxiety* ***_Reduce Craving for Cigarettes_*** ***_Reduce SYMPTOMS of nicotine WITHDRAWAL_***

**Bupropion SR = Zyban** **DOSING**

**_150mg QD for 3 days_** ## Footnote then, **150mg _BID_** Seperate doses by ***_at least 8 hours_*** *_avoid taking second dose @ bedtime_* May continue to smoke for **first 1-2** **weeks**, then select to quit by **2nd week**

**Bupropion = Zyban** **SPECIAL DOSING**

*_CONTAINDICATED WITH_* ***_SEIZURES_*** **Hepatic** Impairment : **150mg Every OTHER Day** **Elderly or Renal** Impairment: **150mg QD** **Side effects with BID dosing --\> 150mg QD**

**Combination Pharmacotherapy**

**LONG-ACTING Formulation + *_Short Acting Formulation_*** **LONG ACTING:** **Bupropion SR / Nicotine Patch / Chantix** Produces relatively CONSTANT levels of nicotine ***_Short Acting:_*** **NRT Gum + Lozenge / Nicotine Nasal Spray + Inhaler** Allows for ACUTE dose titration

**S/Sx of nicotine OVERDOSE**

**N/V/D** **Headache / Ab-pain+cramps** **Cold Sweats / Breathing difficulties** **AGITATION / RAPID HR** **Ringing in the ears**