Respiratory: Tobacco Cessation Flashcards
The 5 A’s
Ask Advise Assess Assist Arrange
Ask….
about tobacco use
Advise….
tobacco users to quit
Assess….
readiness to make a quit attempt
Assist….
with the quit attempt
Arrange…
follow up care
Nicotine absorption
in acidic media…ionized = poorly absorbed
in alkaline media…nonionized = well absorbed
Pharmacology Factors quitting smoking
Alleviation of withdrawal symptoms
Weight Control
Pleasure, mood modulation
Environment Factors
Tobacco advertising
Conditioned Stimuli
Social interactions
Environment Factors
Tobacco advertising
Conditioned Stimuli
Social interactions
Most notable CYP interaction with smoking?
induction CYP1A2, due to hydrocarbons not the actual nicotine
reducing effects of drugs metabolized by CYP1A2
By how much should you reduce caffeine intake when quitting smoking?
~50%
Smoking DDI with hormonal contraceptives?
increased risk of serious CV adverse effects…stroke, MI, thromboembolism. doesn’t effect effectiveness of contraceptive
esp women 35+
benefits of quitting smoking best at what age?
any age, no matter when pt will see benefits
earlier the better
How many years do you get back when you quit
Average about 10 if quit at 40
Most popular cessation program
1-800-QUITNOW
What are tobacco Quit-lines
Free to everyone, staffed locally and offers personalized sessions
better success rate than trying alone
Withdrawal from smoking occurrence
most symptoms manifest within first 1-2 days, peak 1st week and subside after 2-4 weeks
Withdrawal from smoking occurrence
most symptoms manifest within first 1-2 days, peak 1st week and subside after 2-4 weeks
Nicotine Replacement Therapy precautions
recent MI within last 2 weeks
Serious arrhythmias
Serious or worsening angina
How to choose between 2mg or 4mg dose for Nicotine Gum or Lozenge?
Based on time to first cigarette
2mg = smod >30min waking up 4mg = smoke <30min of waking up
How to choose between 2mg or 4mg dose for Nicotine Gum or Lozenge?
Based on time to first cigarette
2mg = smoke >30min waking up 4mg = smoke <30min of waking up
Recommended Gum and Lozenge Dosing
Weeks 1-6 = 1 piece q1-2h
Weeks 7-9 = 1 piece q2-4h
Weeks 10-12 = 1 piece q4-8h
Max lozenges per day?
20
Max gum per day?
24
Directions for using nicotine gum
Chew slowly
Stop chewing at 1st sign of peppery taste/tingle
Park between cheek/gum
Chew again when peppery taste/tingle fades
Directions for nicotine lozenge
Don’t chew or swallow
move around mouth
Minimum of gm/lozenge should be used in 1st 6 weeks?
9 pieces per day to improve changes of quitting
Nicotine gum/lozenge additional info
won’t have same rapid satisfaction that smoking provides
avoid acidic beverages before/after 15min
Adverse effects of nicotine gum
jaw muscle ache
may stick to dental work
How to decide dosing of nicotine patch
based on cigarettes per day
<10 = Step 2 (14mg X 6 wk), Step 3 (7mg X 2 wk) >10 = Step 1 (21mg X 6 wk), Step 2 (14mg X 2 wk), Step 3 (7mg X 2 week)
NicoDerm CQ
How to decide dosing of nicotine patch
based on cigarettes per day
<10 = Step 2 (14mg X 6 wk), Step 3 (7mg X 2 wk) >10 = Step 1 (21mg X 6 wk), Step 2 (14mg X 2 wk), Step 3 (7mg X 2 week)
NicoDerm CQ
Directions of Patch use
use skin on upper body or upper outer part of arm
make sure skin is clean
Apply to different area each day, don’t reuse area for ~ week
Don’t use for more than 24hrs
Don’t cut the patch
Remove before MRI
Nicotine Patch side effects
some skin effects
Insomnia and Vivid dreams/abnormal dreams
Nicotine Inhaler (RX)
used kinda like a cigarette
puff like pipe, want to absorb into oral mucosa
Bupropion SR clinical effects
degrees craving for cigarette
decrease symptoms of nicotine withdrawal
Bupropion SR pharmacokinetics
extensive CYP2B6 metabolism
1/2 life = 21hrs, metabolites 20-37
8 days for Css
Bupropion contraindications
seizure disorder
current or prior diagnosis of bulimia or anorexia
undergoing abrupt discontinuation of Alc, Benzo, Barbs, antiseptics
don’t take w/ MAOi or within 14 days of stoping
Bupropion Warnings & Precautions
change in mood, suicidal thoughts, neuropsychiatric symptoms.contact provider if experience them
FDA black box warning removed 2016
Bupropion SR Dosing
begin 1-2 weeks before quit date
initial treatment: 150mg po q AM fr 3 days, then 150mg po BID for 7-12 wks.
must give dose at least 8hrs apart, no taper when end
Common Bupropion SR side effects
insomnia - avoid bedtime
dry mouth
nausea
Advantages Bupropion SR
might delay weight gain
oral dosing is easy
benefit those with depression
relatively cheap
Disadvantages Bupropion SR
seizure risk increased
contraindications and precautions in some patients
monitor for neuropsychiatric symptoms
Varenicline clinical effects
decrease symptoms of nicotine withdrawal
blocks dopaminergic stimulation responsible for reinforcement and reward associated with smoking
Varenicline Warnings and precautions
had black box then removed
watch for neuropsychiatric events
Varenicline Side effects
rare but have not been causally linked
Varenicline Dosing
Start 1 week prior to quit date
Day 1-3 = 0.5mg qd
Day 4-7 = 0.5mg bid
Day 8-end (~8 wks) = 1mg bid
Fixed Quit approach
set quit date for 1 wk after starting varenicline
continue treatment for 12 weeks
Flexible Quit approach
Start taking and ick a quit date between 8-35 days rom treatment initiation
continue for 12 weeks
Gradual Quit approach
start taking and reduce smoking by 50% within 1st 4 weeks, an additional 50% in next 4 weeks and continue until complete abstinence by 12 weeks
Varenicline additional info
Doses should be taken after eating with a full glass of water
Nausea/Insomnia usually temporary SE
Can experience wild and vivid dreams
1st line for smoking cessation
Varenicline or NRT combo
