Medications for Cessation Flashcards
NICOTINE REPLACEMENT THERAPY (NRT) RATIONALE for USE
- 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
NRT: PRECAUTIONS
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
NICOTINE GUM
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
NICOTINE LOZENGE
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
NICOTINE GUM & LOZENGE: DOSING
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
NICOTINE GUM: DIRECTIONS FOR USE
- 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
NICOTINE LOZENGE: DIRECTIONS for USE
- 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
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?
- 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
Lozenge/Gum Adverse Effects
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
TRANSDERMAL NICOTINE PATCH
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
TRANSDERMAL NICOTINE PATCH DIRECTIONS
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
TRANSDERMAL NICOTINE PATCH DOSING
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
Nicotine Patch: Patient Education
- Water? Cutting? MRIs?
- Skin reactions?
- 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
TRANSDERMAL NICOTINE PATCH: Adverse Effects
Irritation at the patch application site (generally within the first hour)
- Mild itching
- Burning
- Tingling
Sleep disturbances
- Abnormal or vivid dreams
- Insomnia
NICOTINE INHALER + DOSING
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
NICOTINE INHALER: DIRECTIONS for USE
- 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
NICTONE INHALER: Adverse Effects
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
NICOTINE NASAL SPRAY
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
Nasal Spray: Dosing and Administration
- Start with? Increase to?
- At least __ in first __
- Termination? MAX?
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
NICOTINE NASAL SPRAY: DIRECTIONS for USE
- 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
BUPROPION SR + Dosing
- 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
BUPROPION: CONTRAINDICATIONS + CAUTIONS
- 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
BUPROPION: ADVERSE EFFECTS
Common adverse effects:
- Insomnia (avoid bedtime dosing)
- Dry mouth
- Nausea
Less common but reported effects:
- Anxiety/difficulty concentrating
- Constipation
- Tremor
- Skin rash
VARENICLINE (Chantix) + Dosing
- 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
VARENICLINE QUIT APPROACHES
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
VARENICLINE: ADVERSE EFFECTS
Common adverse effects:
- Nausea
- Insomnia
- Abnormal dreams
- Headache
Less common adverse effects:
- Gastrointestinal (flatulence, constipation)
- Taste alteration
VARENICLINE: ADDITIONAL PATIENT EDUCATION
- 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
COMBINATION PHARMACOTHERAPY
Combination NRT [first-line, recommended treatment approach]
- Long-acting formulation (patch)
PLUS
- Short-acting formulation (gum, inhaler, lozenge, nasal spray)
