Pharm Smoking Cessation Flashcards
ID a drug product as nicotine replacement product
Nicotine gum - Nicorette®, Thrive®, Nicorelief®
Nicotine lozenge - Commit®, Nicorette®
Nicotine nasal spray - Nicotrol NS®
Nicotine oral inhaler - Nicotrol®
ID the 5 As that clinicians should employ when advising a patient who smokes
- Ask
- Advise
- Assess
- Assist
- Arrange
Ask
ask about tobacco use: ID and document status for each patient at each visit
Advise
urge every tobacco user to quit
Assess
assess the willingness to quit
Assist
assist in quit attempts: by providing cessation therapies (behavioral + pharmacotherapy)
Arrange
arrange f/u w/i the first week after the quit date to evaluate meds for efficacy and adverse effects
- For patients who are unwilling to quit, provide interventions to increase future quit attempts
- this falls under “assist”
- What are the 5 Rs?
- relevant
- risks
- rewards
- roadblocks
- repeat
ID the benefits and place in therapy for behavioral counseling for smoking cessation
- providing 4-7 + sessions increase cessation rates
- longer sessions (>10min) are associated w/ increased success
- the more formats you provide, the higher the quit rates (QUIT line; pamphlets not as effective)
Contraindications for nicotine gum
- TMJ - vigorous chewing can exacerbate
- Dental appliances - can be damaged by gum or cause difficulties
- Poor dentition - difficulty chewing to get max effect
When to use the 2mg dose of nicotine gum
- <25 cigs/day
- if you smoke your first cig more than 30 mins after waking up
When to use the 4mg dose of nicotine gum
- > or equal to 25 cigs/day
- if you smoke your fist cig w/i 30 min of waking up
What is the recommended dosing schedule for nicotine gum?
- 1st 6 weeks: 1 piece every 1-2 hrs
- next 3 weeks: 1 piece every 2-4 hrs
- additional 3 weeks: 1 piece every 4-8 hrs
- then dc
- max benefit from scheduled use vs. waiting for craving
what is the daily max number of pieces of nicotine gum?
24
What is the appropriate chewing technique for nicotine gum
- “chew and park”
- chew gum until you taste a peppery/minty flavor then park b/w gum and cheek for 30 min. to help w/ absorption
- repeat until taste is gone
- avoid food/drink 15 min. before or during treatment
- avoid acidic beverages before and during use
Adverse effects of nicotine gum
- mouth soreness
- dyspepsia
- hiccups
- jaw ache
- n/v
- abdominal pain
- constipation
- excessive salivation
- mouth ulcers/irritation
based on smoking hx, how do you select the correct dose for a nicotine lozenge?
same as for the gum
recommended dosing schedule for nicotine lozenge
- weeks 1-6: 1 lozenge every 1-2 hrs
- weeks 7-9: 1 lozenge every 2-4 hrs
- weeks 10-12: 1 lozenge every 4-8 hrs
adverse effects of nicotine lozenges
- heartburn
- hiccups
- coughing
- n/v/d
- HA
- abdominal pain
what is the daily max number of nicotine lozenges?
do not use more than 5 lozenges in 6 hours or more than 20 lozenges per day
What NRT has the most rapid onset and most closely mimics the nicotine concentrations in the brain?
nicotine nasal spray
Which NRT has the highest dependence potential?
nicotine nasal spray
What should you avoid before using the NRT products orally?
food and drink
contraindications for the nicotine nasal spray
reactive airway dz (asthma)
adverse effect associated w/ nicotine nasal spray
moderate to severe nasal irritation
adverse effects associated w/ the nicotine inhaler?
- local mouth irritation
- coughing
- rhinitis
directions with the nicotine patch
- worn for 24 hrs, removed and replaced each morning
- apply patch as soon as you wake up
- remove old patch and apply new one to hairless location b/w neck and waist
how to manage skin irritation secondary to the nicotine patch
- rotate patch site
- use 1% hydocortisone cream
how to manage insomnia secondary to the nicotine patch
-remove patch prior to bedtime
dosing strategy for varenicline (Chantix)
- days 1-7 before quit date: 0.5mg daily X 3 days, 0.5 mg BID X 4 days
- maintenance dose (starting day 8): 1 mg BID x 11 weeks
side effects of varenicline (Chantix)
- CNS side effects: insomnia, abnormal dreams, HA, suicidal ideation, depression, irritability, anxiety, agitation
- GI: nausea (very high occurrence), constipation, dysguesia, abdominal pain
- CVS: chest pain, angina
dosing strategy for buproprion (Zyban)
- begin 1-2 weeks before quit date
- 150 mg PO daily x 3 days, increase to 150mg BID for 7-12 weeks
- consider maintenence of 150mg BID x 6 mos
- can be used w/ or w/o NRT
side effects of buproprion (Zyban)
- insomnia
- dry mouth
- tremor
- rash
- HA
how to manage insomnia secondary to buproprion (Zyban)
take evening dose earlier
contraindications to buproprion (Zyban)
avoid in patients w/ a hx of seizures, eating disorders or use of MAOI w/i 14 days
special populations
- should always receive behavioral modification
- includes:
- light smokers (<10 cigs/day)
- pregnant/breastfeeding
- psychiatric illness
- CVD
- adolescents
- pts concerned w/ weight gain
- hospitalized pts
light smokers
- little evidence supporting effectiveness of therapies
- may need dosing adjustments
pregnant/breastfeeding
- to be be encouraged to quit w/o pharmacotherapy
- the earlier the better
- use smallest effective dose but consider risk vs. benefit
- safety date for NRT is variable but less nicotine is delivered to fetus than w/ cigs
- buproprion may cause miscarriage and congenital anomalies in 1st trimester
- no data for varenicline
psychiatric illness
- higher smoking prevalence
- greater tobacco related morbidity and mortality
- greater risk of relapse during cessation attempts
- many psych meds interact w/ smoking cessation
- options: NRT; reasonable success w/ buproprion; can consider varencicline but monitor
CVD
- NRT: overall safe, may consider lower dose; patch generally safe but not recommended in recent MI
- buproprion: safe and effective
- varenicline: small increased risk of certain CV ADRs - weigh benefit vs. risk
Adolescent/peds
- behavioral modification is mainstay
- patch or gum has shown to be safe
- in the US a prescription is required to allow people under 18 to buy patches or gum
pts concerned w/ wight gain
- no tx prevents it
- lozenge, gum and buproprion may delay it
- general gain is fewer than 10 pounds but can be up to 30
- be honest about it
- encourage exercise and healthy diet - make referrals if needed
hospitalized patients
- unique opportunity - smoke free hospital policy and possible motivation to quit d/t illness that led to hospitalization
- combo counseling and transdermal patch have been used
- post-hospitalization f/u is key
