EXAM 3 Nicotine Use Disorder Dr. Dahl Flashcards
What is the most effective approach for smoking cessation? Pharmacotherapy or behavioral intervention?
Both are, based on guidelines
Health Impacts - smoking
-Physiologic: proinflammatory, impaired immune function, vasoconstriction, increased BP and cardiac output, more oxygen demand
-CV disease: stroke, cardiac death, ACS (acute coronary syndrome), peripheral vascular disease
Health Impacts on lungs - smoking
-emphysema
-asthma
-chronic bronchitis
-chronic obstructive pulmonary disease (COPD)
-Lung cancer
others: T2DM, cataracts (eye), erectile dysfunction, rheumatoid arthritis, decreased wound healing
Issues associated with Smokeless Tobacco
-periodontal
->Gingival recession
->Bone attachment loss
->Dental caries
-oral leukoplakia
-cancer: oral, pharyngeal, esophageal, pancreatic
Which receptors are affected by Nicotine?
-Dopamine
-Serotonin
-Norepinephrine
-Acetylcholine
-Glutamate
-GABA (reduction of anxiety and tension)
When after cessation do symptoms start?
starts within 24h -> peak 24-72h
may persist for days, weeks, or longer
-anxious
-cravings
-frustration
-irritability
-impatience
-hostility
-Insomnia
-Restlessness
-difficulty concentrating
Which test is used to assess readiness for smoking cessation?
-Fagerstorm test
low dependence (1-2)
low-moderate (3-4)
moderate (5-7)
high dependence (8+)
-Why I Smoke, Likert scale
18 questions -> helpful to find behavioral interventions
Stages of Quitting
Stage 1: not ready within the next month
Stage 2: ready within the next month
Stage 3: recent quit with last 6 months
Stage 4: former tobacco user who quit more than 6 months ago
What DDIs are associated with smoking?
-many DDIs are caused by tobacco not nicotine
-CYP 1A2 induction
How to dose adjust when CYP1A2 substrates are used?
Not a prodrug: Clozapine, Caffeine
CYP1A2 induction -> lower concentration
->while smoking: may need a higher dose
->when quitting: lower doses
Prodrug: Clopidogrel
CYP1A2 induction -> higher concentration
while smoking: lower dose
while quitting: may need a higher dose
How does nicotine affect caffeine effects when quit smoking?
CYP1A2 induction goes down -> less caffeine metabolism -> higher concentration
-> increased caffeine effects: agitation, alert, HR goes up -> this may worsen withdrawal
->cut caffeine consumption
Which drugs increase the risk for CV events even more with heavy smoking?
estrogen-containing contraceptives
-> Increase in thrombin activity, clotting factor production
-highest risk in heavy smoking (>15 cigarettes per day) and age >35
->endothelial dysfunction, changes in coagulation -> CV risk
-both increase the risk for clotting by themself, now combined even higher risk
What other DDI are expected
-Some benzodiazepines
-some antidepressants
-some antipsychotics
-beta-blockers
-inhaled insulin
-warfarin
What would a Quit Plan look like?
-QUIT DATE – should be set -> Within 2 days to 2 weeks
-Top reasons for quitting
-Smoke-free-vision
-Top triggers à Top coping strategies
-Support system
Triggers Coping strategies
-Stimulation: walk or jog to boost energy
-Handling: pencil, paper clip, stress ball
-Pleasure: alternative activities or “rewards”
-Relaxation: stress relief
-Cravings: mindfulness and medications
-Habit: Avoid situations, inform others of change
Motivational Interviewing
READS
Rolling with resistance
Express empathy
Avoid arguing
Develop discrepancy
Support Self-efficacy
Best way to treat
Medications + Counseling = MORE effective
Who might not be eligible for medical treatment in smoking cessation?
-Pregnant smokers (nictione is harmful for the baby)
-Smokeless tobacco users
-Smoking less than 10 cigarettes per day
-Adolescents < 18 years old
What are the 1st line options for medical smoking cessation?
-NRT
Non-NRT
-Bupropion
-Varenicline (more effective for monotherapy)
-> Combination therapy with short-acting and long-acting (patch) NRT is more effective than monotherapy!
-> when they use a patch also offer a gum or lozenge (short-acting)
Which approach to take in treatment-resistant patients?
may increase the dose of the 1st line drug or change to varenicline
-combinations: short-acting + long-acting (if not tried already)
OR
NRT + non-NRT medication (bupropion or chantix)
3rd line options
will not be the right answer on the exam
-Nortriptyline
-Clonidine: patients with agitation as a withdrawal symptom (may try clonidine if their BP is okay)
Which medical drug should be avoided in patients with a history of seizures?
Bupropion
it lowers the seizure threshold
Must patients stop smoking before they start nicotine products?
the package says to start after quitting
-clinically it might be fine to smoke a bit while on the patch, gum or lozenges
-> with nasal spray they might wait until they quit
What is on the label of OTC NRT products?
relative contraindication if they had a recent MI or arrhythmia
nicotine causes vasoconstriction, increases BP
->clinically they may use NRT even after MI
What are the signs of nicotine toxicity?
-GI: N/V/D
-heart goes up
-cold sweats
-blurry vision
-dizziness, headache
-drooling
OTC precaution
-heart disease: recent MI (2 weeks), uncontrolled HTN with meds, arrhythmias
-active stomach ulcer
-pregnancy
-under 18
-> may still be used under the supervision of a provider
Nicotine Gum dosing
first cigarette within the first 30 min: 4 mg
after 30 min: 2 mg
-> Lozenges preferred in those who have temporomandibular joint (TMJ) disease or dental work done
ADE: jaw muscle soreness (are they chewing too much? -> they should do chew and park to prevent releasing too much nicotine by too much chewing)
What is the max amount of Nicotine gums per day?
24 pieces
Lozenge dosing
first cigarette within the first 30 min: 4 mg
after 30 min: 2 mg
allow to dissolve slowly over 20-30 min
rotate areas in the mouth
Patient that smoked a lot, which product may fit
Gum or lzenge bc it is a oral substitute and might delay weight gain
use at least 9 pieces a day to increase efficacy in the initial week
What should you avoid before using gum or lozenges?
no food or beverage 15 min before or during use
What are the dose instructions for nasal sprays as NRT?
2 sprays (1 in each nostril) = 1 dose
Use 1-2 doses/h - max: 5 doses/h
8-40 doses/day - max: 40 doses/day
avoid in chronic nasal disorders (rhinitis, nasal polyps, sinusitis)
Which dose of transdermal nicotine patches are used?
it comes in 7, 14, 21 mg
> 10 cigarettes per day: start at 21 mg
<10 cigarettes per day: start at 14 mg
How to treat skin irritations with transdermal nicotine patches?
local skin irritations are normal (around the area of application) -> use hydrocortisone cream
if extends beyond that area or hydrocortisone cream doesn’t help -> REFER
When should NRT patches be removed?
-change after 24h
-bothersome dreams
-sleep disturbances
-MRI screen -> it may cause burns bc it can contain metal
What are the contraindications of Bupropion use?
-seizure disorder
-anorexia nervosia and bulimia
-MAO inhibitors
When should Bupropion treatment be started?
1-2 weeks before Quit Date
-it needs time before we have enough levels in the system
treat for 7-12 weeks
How long should you treat with Bupropion?
treat for 7-12 weeks
may extend to 6-12 months
Which formulation of Bupropion is approved for smoking cessation therapy?
12h Sustained released (SR) formulation
if they are taking it twice a day make sure there is an 8h gap in between
MOA Varenicline (Chatnix)
blocks the nicotinic receptor (α4β2) and partially agonizes them
-Chantix will cause moderate levels of dopamine - so not the same sensation as with smoking
When to initiate Varenicline therapy?
-Begin 1 week before Quitting
OR
SLOW TURKEY
-begin 8-35 days before quitting
-Start Chantix and slowly cut back smoking (50% every 4 weeks) -> abstinence at 12 weeks (may need to extend Chantix therapy afert quitting)
What are the common side effects of Varenicline?
Nausea !!! -> take after eating with a full glass of water
also headache, insomnia, abnormal dreams
When to consider alternative treatment strategies?
Not on exam
very heavy smokers:
-combine Bupropion + Varenicline
(CAUTION: bupropion had a BBW for depressed mood, agitation, suicidal thoughts, suicide attempts)
heavy side effects with Varenicline (nausea):
lower the dose
1mg daily or 0.5 mg BID
side effects with Bupropion (dry mouth, headaches, etc): low dose
150 mg once daily
-agitation withdrawal: add clonidine
-OFF-label use of higher dose of Varenicline and nicotine patch (42 mg, double the dose)
