tobacco

Question 1

Transdermal Patch

general dosing

Answer 1

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

Question 2

Transdermal Patch

Advantages

Answer 2

● 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

Question 3

Transdermal Patch

Disadvantages

Answer 3

●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

Question 4

Nicotine gum

general dosing

Answer 4

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

Question 5

Nicotine gum

advantages

Answer 5

● Effect within 15 minutes
● Patient controlled, easy to titrate dose
● May delay weight gain

Question 6

Nicotine gum

disadvantages

Answer 6

● 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

Question 7

Nicotine Lozenges

general dosing

Answer 7

● 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

Question 8

Nicotine Lozenges

advantages

Answer 8

● Effect within in 15 min
● Max absorption 20 min
● Easy to use and conceal
● Patient can titrate to effect
● Good with dentures/dental work

Question 9

Nicotine Lozenges

disadvantages

Answer 9

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

Question 10

Nicotine Inhaler

general dosing

Answer 10

● 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

Question 11

Nicotine Inhaler

advantages

Answer 11

● Effect within 15 minutes
● Patient can titrate to effect
● Mimics the hand to mouth ritual of smoking
● Good with dentures/dental work

Question 12

Nicotine Inhaler

disadvantages

Answer 12

● 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

Question 13

Nicotine mouth spray
Nicorette quick mist (1 mg)
general dosing

Answer 13

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

Question 14

Nicotine mouth spray

advantages

Answer 14

● Rapid onset: within 60 seconds
● can titrate
● Absorbed through oral mucosa

Question 15

Nicotine mouth spray

disadvantages

Answer 15

● 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

Question 16

NRT AE

Answer 16

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

Question 17

Bupropion

MOA

Answer 17

inhibitor of the neuronal uptake of norepinephrine, serotonin and dopamine MOA in smoking cessation unknown.
- also indicated for depression

Question 18

Varenicline: ɑ4β2 nicotinic acetylcholine receptors

MOA

Answer 18

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

Question 19

Bupropion
(Zyban, Wellbutrin)

general dosing

Abstinence at 12 months: 18.5% vs PB 6.6%

Answer 19

● 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

Question 20

Bupropion

Advantages

Answer 20

● Oral formulation
● May benefit patients with co-existence depression
● Can be initiated before quit date
● No risk of nicotine toxicity
● May delay weight gain

Question 21

Bupropion

disadvantages

Answer 21

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

Question 22

Varenicline
(Champix)

general dosing

Abstinence at 12 months 22% vs BUP 15% vs PB 9%

Answer 22

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

Question 23

Varenicline

Advantages

Answer 23

● 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

Question 24

Varenicline

disadvantages

Answer 24

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

Question 25

Nortriptyline
(Aventyl)

general dosing

off label
Abstinence at 12 months 17% vs PB 7%

Answer 25

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

Question 26

Nortriptyline
(Aventyl)

advantages

Answer 26

● Inexpensive
● Consider if also: pain, migraine, depression,
neuropathy, insomnia

Question 27

Nortriptyline
(Aventyl)

disadvantages

Answer 27

Less studied
Common AE: dry mouth, blurred vision, constipation, dizziness, sedation.
Less common AE: confusion, arrhythmias, urinary retention

Question 28

Clonidine

● Off label

Answer 28

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

Question 29

Clonidine
● Off label

advantages

Answer 29

● Inexpensive

Question 30

Clonidine
● Off label

disadvantages

Answer 30

Less studied
Common AE: sedation, dizziness, hypotension, dry mouth.
Less common AE: anxiety, irritability, memory problems

Question 31

non-pharm

Answer 31

● 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.