43. Tobacco Cessation Flashcards
Treatment guidelines recommend behavioral counseling alone (no meds) for certain patient populations. What are they?
Pregnant women
Adolescents
Smokeless tobacco users (e.g. chewing tobacco)
“Light smokers” (<10 cigs/day)
Non-nicotine chemicals in tobacco smoke induce CYP450 enzymes, primarily ___
1A2
Smokers who quit may experience side effects from supratherapeutic levels of _____
Caffeine
Theophylline
Warfarin (R-isomer, less potent)
Others: fluvoxamine, olanzapine, clozapine
What female patient population should not take estrogen-containing oral contraceptives?
women ≥35yo who smoke (increased risk of CV events)
Smokers age ____ should receive a pneumococcal vaccine and influenza vaccine (in addition to other age-appropriate vaccines)
19-64yo
What are OTC nicotine replacement therapy (NRT) options?
Patch, gum, lozenge
(Inhaler and nasal spray is Rx only)
Warnings for NRT
Avoid in immediate post-MI period, life-threatening arrhythmias, severe or worsening angina and pregnancy
Side effects for NRT (all)
Insomnia
Others: HA, dizziness, nervousness, dyspepsia
Side effects for NRT patch
vivid dreams, skin irritation
Side effects for NRT inhaler
Mouth/throat irritation, cough, rhinitis
Side effects for NRT nasal spray
Nasal irritation
Others: watery eyes, sneezing, transient changes in taste/smell
How old do you have to be to buy nicotine products?
≥18yo (need ID to buy)
T/F: nicotine patch must be removed before MRI
Yes
Which strength of gum/lozenges can reduce or delay weight gain?
4mg
How long should you wait to eat/drink before or during gum/lozenge use?
15min
acidic beverages/foods decrease buccal absorption
Which NRT option has the fastest delivery (useful for rapid relief of withdrawal symptoms)?
Nasal spray
Which NRT option has highest risk of dependence?
Nasal spray
Which NRT option has highest adherence rate?
Patch
Patient smokes 1ppd, first cigarette is right after they wake up. What NRT regimen do you recommend?
Patch 21mg x6 weeks (decrease to 14mg x2 weeks, 7mg x2 weeks)
Gum/Lozenge 4mg q1-2h x6 weeks (q2-4h x3 weeks, 4-8h x3 weeks)
Patient smokes 5 cigs/day, first cigarette is during their lunch break. What NRT regimen do you recommend?
Patch 14mg x 6 weeks (decrease to 7mg x2 weeks)
Gum/Lozenge 2mg q1-2h x6 weeks (decrease q2-4h x3 weeks, q4-8h x3 weeks)
MOA of buprorpion
blocks neuronal reuptake of dopamine and/or NE (results in reduced cravings and other withdrawal symptoms)
Dosing for Buproprion SR (Zyban)
150mg QAM for 3 days, then 150mg BID
Max dose: 300mg/day
Use up to 6 months
Boxed warning for bupropion SR (Zyban)
Increased risk of suicidal thinking and behavior in children, adolescents and young adults taking antidepressants
Contraindications for bupropion SR (Zyban)
Seizure
Hx anorexia/bulimia
Concurrent use with MAOi, linezolid, or IV methylene blue
Warnings for bupropion SR (Zyban)
Serious neuropsychiatric events (e.g. mood changes, hallucinations, paranoia, aggression, anxiety)
Others: activation of mania/hypomania, HTN, angle-closure glaucoma, rash (including SJS)
Side effects for bupropion SR (Zyban)
Dry mouth, insomnia, tremors, weight loss
Others: agitation, anxiety, tachycardia, HA, sweating, N/V, constipation
Patient is planning to quit smoking. They were prescribed bupropion. Current med list includes lisinopril, atorvastatin, and Wellbutrin. What is your concern?
Do NOT use bupropion with other forms of buprropion (Wellbutrin is bupropion for depression)
Patient recently started on bupropion and is now experiencing insomnia. What do you recommend?
Take 1st dose upon waking up and 2nrd dose 8 hrs after 1st dose
Patient has been on Bupropion SR for smoking cessation for 5 weeks and has no significant process. What do you recommend?
If no significant process by week 7, consider discontinuation
MOA varenicline (Chantix)
Partial neuronal alpha-4 beta-2 nicotinic receptor agonist - low level stimulation of the receptor while blocking ability of nicotine to bind = relieves symptoms of withdrawal and breaks reinforcement/reward cycle of smoking)
Warnings for varenicline (Chantix)
Serious neuropsychiatric events (e.g. agitation, depression, suicidal thoughts/behaviors)
Seizures
Others: increased effects of alcohol, somnambulism (sleepwalking), accidental injury (e.g. traffic accidents), CVD risk, hypersensitivity reactions (e.g. angioedema, SJS)
Side effects for varenicline (Chantix)
Nausea (~30%, dose dependent)
Insomnia
Abnormal dreams
HA
Others: constipation, vomiting
To decrease nausea a/w Chantix, what do you recommend?
Take after eating with full glass of water; can reduce dose if needed
Patient wants to quit smoking but is concerned of weight gain. What do you recommend?
Gum/lozenges and bupropion SR (all delay weight gain)
Patient wants to quit smoking but also has depression. What do you recommend?
Use bupropion SR
Patient wants to quit smoking but also has a hx of seizures. What do you recommend to avoid?
Avoid bupropion and varenicline
Patient wants to quit smoking but also has a hx of anorexia. What do you recommend to avoid?
Avoid bupropion
How do you use nicotine patches?
Apply to clean, dry, and relatively hairless area (hold ~10 seconds)
Wear for 24 hrs (16hrs if insomnia)
Folding sticky ends together and place back in original pouch and discard
Wash hands after applying and removing patch
Rotate application site (do not apply to same site for at least 1 week, may cause skin irritation)
Never cut patch or wear more than 1 patch at a time
How do you use nicotine gum?
Chew slowly until tingle/peppery flavor
Park between cheek and gum
When tingle/peppery flavor goes away, chew again and then park again
Repeat until all tingle/flavor goes away (~30 min)
Do not eat or drink 15min before or during chewing
