Smoking Cessation

Question 1

What is the mechanism of action of nicotine?

Answer 1

Diffuses rapidly into CNS and binds to nicotinic cholinergic receptors. It also facilitates some dopamine release giving a reward response.

Question 2

What is the mechanism through which nicotine causes tolerance?

Answer 2

Down regulation of nicotinic cholinergic receptors.

Question 3

Describe the mechanism of nicotine withdrawal.

Answer 3

Nicotine cessation results in a subnormal amount of dopamine release leading to malaise, inability to experience pleasure, irritability, restlessness, anxiety, increased hunger, constipation, headache, insomnia, and craving for tobacco

Question 4

What class of drug is nicotine?

Answer 4

Sympathomimetic

Question 5

What is the primary method of attempting to stop people from smoking?

Answer 5

Nicotine replacement

Question 6

What are the ways nicotine replacement can be administered?

Answer 6

Many methods –> gum, patch, nasal spray, inhaler, lozenges

Question 7

What is critical to counsel a patient on before starting nicotine replacement therapy?

Answer 7

They must stop smoking –> the additive effect of smoking with nicotine replacement will make the patient very ill.

Question 8

List methods of nicotine replacement from most effective to least effective.

Answer 8

Patch > gum > spray and inhaler

Question 9

When using the gum, what determines what dose of gum you should start the patient on?

Answer 9

How many cigarettes they smoke per day. 24 or more start on 4mg dose. Less than 24 cigarettes get 2mg dose.

Question 10

How should you instruct patients use nicotine gum?

Answer 10

Chew it a few times then park it for several minutes so the drug is absorbed through the gums.

Question 11

How is the nicotine patch dose and how is it used?

Answer 11

21mg, 14mg, or 7mg. Wherever you start, have them on it for 3-4 weeks then taper down for 2 weeks at each lower dose.

Question 12

What time of day should a new patch be placed and why?

Answer 12

In the morning because nicotine is stimulant

Question 13

How should you manage a patient that is using the patch and complains of a localized rash?

Answer 13

Switch to a different brand of patch –> the adhesive causes the allergy/rash and each brand uses a different adhesive

Question 14

Nicotine lozenges come in 2 and 4 mg doses. What determines which dose you should give to a patient?

Answer 14

If they smoke their cigarette within 30 minutes of waking each morning, use the 4mg dose. Otherwise, use the 2mg dose.

Question 15

When are medications used in smoking cessation?

Answer 15

2nd line –> when a person fails OTC nicotine replacement therapy

Question 16

What is the mechanism of action of bupropion?

Answer 16

Dopamine agonist –> it gives the reward so the patient doesn’t need cigarettes for the reward

Question 17

Define steady state, say how long it takes for bupropion takes to reach steady state, and say why this is clinically relevant.

Answer 17

Steady state is when absorption = metabolism. Bupropion reaches steady state in about 1 week. Set the quit date about 1 week after bupropion is started.

Question 18

How long should bupropion be tried before it is deemed a failure and another method of smoking cessation should be tried?

Answer 18

7 weeks

Question 19

What patients should not be prescribed bupropion?

Answer 19

Seizure patients and eating disorders –> hyponatremia decreases seizure threshold

Question 20

What drug discussed in class is only indicated for smoke cessation?

Answer 20

Varenicline

Question 21

What is the mechanism of action of varenicline?

Answer 21

Antagonist and partial agonist of the nicotine receptor –> relieves withdrawal symptoms but provides little dopamine reward

Question 22

What are the two AEs of varenicline?

Answer 22

Weird dreams and SI

Question 23

Describe the dosing of varenicline.

Answer 23

Varied dosing over different periods for about 3 months total

Question 24

What agents may be considered if bupropion and varenicline can’t be used or the patient fails those medications?

Answer 24

Nortriptyline and clonidine

Question 25

What effect will smoking cessation have on a patient’s prescription medication doses?

Answer 25

Cigarette smoke is an inducer of CP 450. When a smoker suddenly stops, any drug that goes through CP 450 will require a lower dose