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Pharmacy Practice III > Medications for Cessation > Flashcards

Medications for Cessation Flashcards

1
Q

NICOTINE REPLACEMENT THERAPY (NRT) RATIONALE for USE

A
  • Reduces physical withdrawal from nicotine
  • Eliminates the immediate, reinforcing effects of nicotine that is rapidly absorbed via tobacco smoke
  • Allows patient to focus on behavioral and psychological aspects of tobacco cessation

*NRT products approximately doubles quit rates

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2
Q

NRT: PRECAUTIONS

A

Patients with underlying cardiovascular disease

  • Recent myocardial infarction (within 2 wk)
  • Serious arrhythmias
  • Serious or worsening angina

*NRT products may be appropriate for these patients if they are under medical supervision

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3
Q

NICOTINE GUM

A

Nicorette; generics

Resin complex (Nicotine, Polacrilin)

  • Sugar-free chewing gum base
  • Contains buffering agents to enhance buccal absorption of nicotine
  • Available: 2 mg, 4 mg; original, cinnamon, fruit, and mint (various) flavors
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4
Q

NICOTINE LOZENGE

A

Nicorette Lozenge, Nicorette Mini Lozenge; generics

  • Nicotine polacrilex formulation (delivers ~25% more nicotine than equivalent gum dose)
  • Sugar-free mint, cherry flavors
  • Contains buffering agents to enhance buccal absorption of nicotine
  • Available: 2 mg, 4 mg
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5
Q

NICOTINE GUM & LOZENGE: DOSING

A

Dose based on the “time to first cigarette” as an indicator of nicotine dependence

Use the 2 mg gum/lozenge:
- If first cigarette of the day is smoked more than 30 minutes after waking

Use the 4 mg gum/lozenge:
- If first cigarette of the day is smoked within 30 minutes of waking

Week 1-6: 1 piece q 1-2 h
Week 7-9: 1 piece q 2-4 h
Week 10-12: 1 piece q 4-8 h

*DO NOT use more than 24 pieces of gum or 20 lozenges in one day

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6
Q

NICOTINE GUM: DIRECTIONS FOR USE

A
  • Chew slowly
  • Stop chewing at first sign of peppery taste or tingling sensation
  • Park between cheek & gum
  • Chew again when peppery taste or tingle fades
  • Repeat
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7
Q

NICOTINE LOZENGE: DIRECTIONS for USE

A
  • Place in mouth and allow to dissolve slowly (nicotine release may cause warm, tingling sensation)
  • Do not chew or swallow
  • Occasionally rotate to different areas of the mouth
  • Lozenges will dissolve completely in about 20-30 minutes
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8
Q

Nicotine Gum/Loz. Patient Education

  • How many pieces should a PT use at first?
  • Effectiveness can be reduced by?
  • Avoid food/drink for?
  • Incorrect chewing technique can lead to?
A
  • To improve chances of quitting, use at least 9 pieces daily during the first 6 weeks
  • The gum/lozenge will not provide the same rapid satisfaction that smoking provides
  • The effectiveness of the nicotine gum/lozenge may be reduced by some foods and beverages: coffee, wine, juices, soft drinks
  • Do NOT eat or drink for 15 minutes BEFORE or while using the nicotine gum or lozenge

Incorrect chewing technique can:

  • Light headedness/dizziness
  • Nausea and vomiting
  • Hiccups
  • Irritation of throat and mouth
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9
Q

Lozenge/Gum Adverse Effects

A

Adverse effects of nicotine gum and lozenge:

  • Mouth and throat irritation
  • Hiccups
  • Gastrointestinal complaints (dyspepsia, nausea)

Adverse effects associated with nicotine gum:

  • Jaw muscle ache
  • May stick to dental work
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10
Q

TRANSDERMAL NICOTINE PATCH

A

Habitrol; NicoDerm CQ; generic

  • Continuous (24hr) nicotine delivery system
  • Nicotine is well absorbed across the skin
  • Transdermal delivery to systemic circulation avoids hepatic first-pass metabolism
  • Plasma nicotine levels are lower and fluctuate less than with smoking
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11
Q

TRANSDERMAL NICOTINE PATCH DIRECTIONS

A

Directions:

  • Choose area on upper body/upper outer part of arm
  • Make sure skin is clean, dry, hairless, not irritated
  • Apply patch to different area each day
  • Do not use same area again for at least 1 week
  • Remove protective liner, apply adhesive side to skin
  • Peel off remaining protective covering
  • Press firmly with palm of hand for 10 seconds
  • Make sure patch sticks well to skin, esp around edges
  • Wash hands: Nicotine on hands can get into eyes or nose and cause stinging or redness
  • Do not leave patch on skin for more than 24 hours—doing so may lead to skin irritation
  • Adhesive remaining on skin may be removed with rubbing alcohol or acetone
  • Dispose of used patch by folding it onto itself, completely covering adhesive area
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12
Q

TRANSDERMAL NICOTINE PATCH DOSING

A

NicoDerm CQ, Habitrol/Generic:

  • Light smoker =< 10 cigs/day
  • Step 2: 14 mg x 6 wk
  • Step 3: 7 mg x 2 wk
  • Heavy smoker > 10 cigs/day
  • Step 1: 21 mg x 6 wk
  • Step 2: 14 mg x 2 wk
  • Step 3: 7 mg x 2 wk
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13
Q

Nicotine Patch: Patient Education

  • Water? Cutting? MRIs?
  • Skin reactions?
A
  • Water will not harm the nicotine patch if it is applied correctly; patients may bathe, swim, shower, or exercise while wearing the patch
  • Do not cut patches to adjust dose (can effect nicotine delivery, may be less effective)
  • Keep new and used patches out of the reach of children and pets
  • Remove patch before MRI procedures
  • After removal, skin may be red for 24 hr (more than 4 days or swells = PCP)
  • Local skin rxn (red, burn, itch) *avoid use of pt in dermatological issues
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14
Q

TRANSDERMAL NICOTINE PATCH: Adverse Effects

A

Irritation at the patch application site (generally within the first hour)

  • Mild itching
  • Burning
  • Tingling

Sleep disturbances

  • Abnormal or vivid dreams
  • Insomnia
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15
Q

NICOTINE INHALER + DOSING

A

Nicotrol Inhaler

  • Mouthpiece + cartridge with porous plug
  • Delivers 4 mg nicotine vapor, in buccal mucosa

Initial treatment (up to 12 weeks)

  • Start with at least 6 cartridges/day during the first 3–6 weeks of treatment
  • Increase prn to maximum of 16 cartridges/day
  • In general, use 1 cartridge every 1–2 hours

Gradually reduce daily dosage over the following 6–12 weeks

Recommended maximum duration of therapy is 6 months

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16
Q

NICOTINE INHALER: DIRECTIONS for USE

A
  • Align marks on mouthpiece
  • Pull and separate mouthpiece into two parts
  • Press nicotine cartridge firmly into bottom of mouthpiece until it pops into place
  • Line up the markings on the mouthpiece again and push the two pieces back together so they fit tightly
  • Twist the top to misalign marks and secure unit
  • Inhale into back of throat or puff in short breaths
  • Nicotine in cartridges is depleted after about 20 minutes of active puffing
  • Mouthpiece is reusable; clean regularly with mild detergent
17
Q

NICTONE INHALER: Adverse Effects

A

Adverse effects associated with the nicotine inhaler include:

  • Mild irritation of the mouth or throat
  • Cough
  • Hiccups
  • Gastrointestinal complaints (dyspepsia, nausea)

*Severity generally rated as mild, and frequency of symptoms declined with continued use

  • Use at room temp
  • Do NOT eat or drink for 15 minutes BEFORE or while using the nicotine inhaler
18
Q

NICOTINE NASAL SPRAY

A

Nicotrol NS

Aq. solution of nicotine in a 10-ml spray bottle

  • Each metered dose actuation delivers
  • 50 mcL spray
  • 0.5mgnicotine
  • ~100 doses/bottle
  • Rapid absorption across nasal mucosa
19
Q

Nasal Spray: Dosing and Administration

  • Start with? Increase to?
  • At least __ in first __
  • Termination? MAX?
A

One dose = 1 mg nicotine
(2 sprays, one 0.5 mg spray in each nostril)

  • Start with 1–2 doses per hour
  • Increase as needed to max of 5 doses per hr or 40 mg (80 sprays; ~1⁄2 bottle) daily
  • At least 8 doses daily for the first 6–8 wk

Termination:

  • Gradual tapering over an additional 4–6 weeks
  • Recommended maximum duration of therapy is 3 months
20
Q

NICOTINE NASAL SPRAY: DIRECTIONS for USE

A
  • Press in circles on sides of bottle and pull to remove cap
  • Prime the pump (before first use) (re-prime if not used for 24 hr)
  • Blow nose (if not clear)
  • Tilt head back slightly and insert tip of bottle into nostril as far as comfortable
  • Breathe through mouth, and spray once in each nostril
  • Do not sniff or inhale while spraying
  • If nose runs, gently sniff to keep nasal spray in nose
  • Wait 2–3 minutes before blowing nose
  • Avoid contact with skin, eyes, and mouth
21
Q

BUPROPION SR + Dosing

A
  • Non-nicotine cessation aid
  • MOA: AD affect levels of brain neurotransmitters (dopamine/norepinephrine)
  • Clinical effects: decrease craving for cigs and sx of withdrawal

*Start 1-2 wk PRIOR to quit date
Dosing
- Initial tx: 150 mg q AM for 3 days
- Then: 150 mg po BID for 7-12 wk

22
Q

BUPROPION: CONTRAINDICATIONS + CAUTIONS

A
  • Seizure disorder
  • Current or prior diagnosis of bulimia or anorexia nervosa
  • Abrupt discontinuation of alcohol, benzodiazepines, barbiturates and antiepileptic drugs
  • Use of MAO inhibitors (within 14 days of initiating or discontinuing therapy)

Caution In:

  • elevated risk for seizures
  • neuropsychiatric conditions / sx
  • risk of suicide
23
Q

BUPROPION: ADVERSE EFFECTS

A

Common adverse effects:

  • Insomnia (avoid bedtime dosing)
  • Dry mouth
  • Nausea

Less common but reported effects:

  • Anxiety/difficulty concentrating
  • Constipation
  • Tremor
  • Skin rash
24
Q

VARENICLINE (Chantix) + Dosing

A
  • Nonnicotine cessation aid, partial nicotinic receptor agonist, decreases withdrawal sx
  • Start 1 week PRIOR to quit day
  • Day 1-3: 0.5 mg QD
  • Day 4-7: 0.5 mg BID
  • Day 8-12: 1 mg BID
25
Q

VARENICLINE QUIT APPROACHES

A

FIXED QUIT approach

  • Set quit date for 1 week after starting varenicline
  • Continue tx for 12 weeks

FLEXIBLE QUIT approach

  • Start taking varenicline and pick a quit date between 8 to 35 days from tx initiation
  • Continue treatment for 12 weeks

GRADUAL QUIT approach
- Start taking varenicline and reduce smoking by 50% within the first 4 wk, an additional 50% in the next 4 wk, and continue until complete abstinence by 12 wk

26
Q

VARENICLINE: ADVERSE EFFECTS

A

Common adverse effects:

  • Nausea
  • Insomnia
  • Abnormal dreams
  • Headache

Less common adverse effects:

  • Gastrointestinal (flatulence, constipation)
  • Taste alteration
27
Q

VARENICLINE: ADDITIONAL PATIENT EDUCATION

A
  • Doses should be taken after eating, with a full glass of water
  • May experience vivid, unusual or strange dreams during treatment
  • Use caution driving, drinking alcohol, and operating machinery until effects of quitting smoking with varenicline are known
28
Q

COMBINATION PHARMACOTHERAPY

A

Combination NRT [first-line, recommended treatment approach]
- Long-acting formulation (patch)
PLUS
- Short-acting formulation (gum, inhaler, lozenge, nasal spray)

Pharmacy Practice III (16 decks)

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