tobacco Flashcards
Transdermal Patch
general dosing
24 hour: Habitrol + generic (matrix)
General dosing:
● 6 wks at higher strength followed by 2 wks at intermediate and 2 wks at lowest strength
●Traditional vs titration approach
Transdermal Patch
Advantages
● Steady-state nicotine levels are achieved throughout the day (16 -24 hours)
● Easy to use and conceal
● Improved compliance
● Can be used in combination with other NRT products
● Fewer AE
Transdermal Patch
Disadvantages
●Requires 2-3 days to get maximal serum levels
●Reservoir: cannot be cut
●Local irritation to nicotine, adhesive, or allergic reactions or to the adhesive may occur
o Rx with topical steroid cream, ICS
o Rotate site
● Patient with underlying dermatologic conditions (psoriasis..) should not use
● Harder to titrate dose
Nicotine gum
general dosing
Nicotine Gum ● Nicorette, Thrive (2mg, 4mg) ● Chew & park” technique General dosing: ● 2 mg – 4 mg; 10-12 pieces per day ● < 15 cigs/day = 2 mg ● > 15 cigs/day=4 mg
Nicotine gum
advantages
● Effect within 15 minutes
● Patient controlled, easy to titrate dose
● May delay weight gain
Nicotine gum
disadvantages
● Gum chewing may not be socially acceptable
● May stick to dental work and denture
● Sore mouth
● Unpleasant taste
● Proper chewing technique (chew/park) needed to minimize adverse effects
● Cannot eat or drink 15 min before or
while using gum
Nicotine Lozenges
general dosing
● 15-25/day ● < 1 pack per day=2mg (Nicorette) = 1mg (Thrive) ● >1 pack per day = 4 mg (Nicorette)=2 mg (Thrive) Suck until strong flavor, then park ● Slowly dissolves in stomach if accidentally swallowed
Nicotine Lozenges
advantages
● Effect within in 15 min ● Max absorption 20 min ● Easy to use and conceal ● Patient can titrate to effect ● Good with dentures/dental work
Nicotine Lozenges
disadvantages
Increased AE if swallowed or chewed.
● No chewing – allow for slow dissolution. (Park/suck)
● Avoid acidic beverages and foods during 15 min pre/post
● Use beyond 6 months not recommended
Nicotine Inhaler
general dosing
● Absorbed from oral mucosa – not lungs
● Each cartridge lasts ~ 20 min of continuous puffing
● 10 puffs = 1 puff of cigarette
● 6 – 12 cartridges/day x 3-12 weeks then wean daily over 6 – 12 wk, or continue as long as necessary
Nicotine Inhaler
advantages
● Effect within 15 minutes
● Patient can titrate to effect
● Mimics the hand to mouth ritual of smoking
● Good with dentures/dental work
Nicotine Inhaler
disadvantages
● Initial throat or mouth irritation (1st week)
● Dry mouth
● cough
● Use with caution in patients with bronchospastic conditions
● Avoid acidic beverages and foods during 15 min pre/post
● Not like smoking: inhale into mouth not lungs
● Store away from light
Nicotine mouth spray
Nicorette quick mist (1 mg)
general dosing
Each spray = 1 mg nicotine
● 150 sprays/canister
General dosing
● 1-2 sprays q30-60 min. max 4 sprays/hr; 64 sprays/day
● Weeks 1-6: 1-2 sprays q30 min. Weeks 7-9: reduce by number of sprays to ½ by end of week 9. Week 10-12; stop treatment when dose reduced to 2-4 sprays per day
Nicotine mouth spray
advantages
● Rapid onset: within 60 seconds
● can titrate
● Absorbed through oral mucosa
Nicotine mouth spray
disadvantages
● Avoid acidic beverages and foods during 15 min pre/post
● Need to prime
● Some alcohol in product
● Unpleasant taste
● Irritation, pain and or tingling of throat, mouth lips
● Dry mouth
NRT AE
o Common AE with NRT: insomnia, nausea, headache
o Demonstrated safety in stable cardiovascular disease
o Possible exceptions
o Unstable angina
o Recent heart attack
o Acute heart failure
o Unstable arrhythmia
Bupropion
MOA
inhibitor of the neuronal uptake of norepinephrine, serotonin and dopamine MOA in smoking cessation unknown.
- also indicated for depression
Varenicline: ɑ4β2 nicotinic acetylcholine receptors
MOA
partial agonist: partial stimulation of receptor mediated release of dopamine in the reward center and competitive inhibitor of receptor binding by nicotine delivered by cigarettes.
Thereby suppressing nicotine withdrawal symptoms
- Nicotine antagonist effects: prevents binding of nicotine.
- caution with psychiatric history
Bupropion
(Zyban, Wellbutrin)
general dosing
Abstinence at 12 months: 18.5% vs PB 6.6%
● Begin 1-2 wks prior to quit date
● 150 mg once daily x 3 days then BID
● Recommended use: 12 wk then taper over 6 - 12 weeks
● Take with food
Bupropion
Advantages
● Oral formulation ● May benefit patients with co-existence depression ● Can be initiated before quit date ● No risk of nicotine toxicity ● May delay weight gain
Bupropion
disadvantages
Slower onset (1-2 wks) Common AE ● Dry mouth & insomnia, agitation, unease ● Titrate the dose down! Less Common AE: ● Risk of seizure is 1/1000 ● Risk factors for seizure ◦ Seizure disorders ◦ Eating disorders ● Drug interactions Contraindications: hx seizures, MAOI use
Varenicline
(Champix)
general dosing
Abstinence at 12 months 22% vs BUP 15% vs PB 9%
12 week course ● Start 1-2 week prior to quit date ● 0.5 mg once daily x 3 days, then ● 0.5 mg BID x 4 days, then ● 1 mg BID x 11 wk ● “Initial dosing pack:” 11 x 0.5 mg tabs; 14 x 1 mg tablets ● Requires dose adjustment in renal disease (max 0.5 mg BID) ● Take with food & water
Varenicline
Advantages
● Reduces nicotine craving, “pleasure” of smoking
● Diminish withdrawal symptoms
● Oral formulation
● Initiate before quit date
● New mechanism of action
● Benefit those who failed other medications
Varenicline
disadvantages
Common AE:
● Nausea (may induce nausea in up to 30%of
patients), insomnia, and abnormal/vivid dreams, taste disturbance
Less Common AE:
● Health Canada warning; Psychiatric effects (not black box)
● Need to titrate
● Post marketing surveillance warning by FDA and Health Canada
- Contraindications: endstage renal, epilepsy, suicidal, pregnancy
Nortriptyline
(Aventyl)
general dosing
off label
Abstinence at 12 months 17% vs PB 7%
Quit day between 1 and 4 weeks
25 mg capsules
Titrate up to 3 capsules (75 mg) a day
Continue min 12 weeks
MOA: tricyclic antidepressants- inhibits reuptake of norepinephrine and serotonin
Nortriptyline
(Aventyl)
advantages
● Inexpensive
● Consider if also: pain, migraine, depression,
neuropathy, insomnia
Nortriptyline
(Aventyl)
disadvantages
Less studied
Common AE: dry mouth, blurred vision, constipation, dizziness, sedation.
Less common AE: confusion, arrhythmias, urinary retention
Clonidine
● Off label
0.1 mg BID po for 3 days before or on the quit date.
Titrate up by 0.1 mg/day po once per week as tolerated to a maximum of 0.4 mg/day. Duration of therapy
ranges from 3–10 weeks
Clonidine
● Off label
advantages
● Inexpensive
Clonidine
● Off label
disadvantages
Less studied
Common AE: sedation, dizziness, hypotension, dry mouth.
Less common AE: anxiety, irritability, memory problems
non-pharm
● Patient education
● Behavioral therapy
● Self-help materials
● Telephone counseling
● Other
o Acupuncture: Evidence of effectiveness not available
o Hypnosis: Insufficient evidence. Suggest combining with behavior modification or counseling
o Laser: No reliable studies support this therapy
o Electronic cigarettes: Only those products without nicotine or health claims can be legally imported and sold in Canada. Health Canada does not recommend using electronic cigarettes due to lack of safety information regarding exposure to vaporized propylene glycol.
