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Therapeutics III > Tobacco - Block 3 > Flashcards

Tobacco - Block 3 Flashcards

1
Q

What are the causes for tobacco dependence?

A
  1. Tolerance
  2. Withdrawal sx
  3. Cravings
  4. Self regulation
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2
Q

What is the DSM 5 criteria for TUD?

A

Considered an addiction if 2 or more apply:
1. Withdrawl sx
2. Tolerance
3. Desire or efforts to cut down/control use
4. Great time spent in obtaining/using
5. Reduced occupational, recreational activities
6. Use despite problems
7. Larger amounts consumed than intended
8. Cravings

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3
Q

What are the role of a pharmacist on tobacco use?

A

Ask about tobacco use and secondhand exposure
Advise to quit
Assess readiness to quit
Assist in quit attempt (counseling, referral)
Arrange for patient to quit

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4
Q

DDI for smokin

A
  1. Induces P450
  2. Affects how the body metabolizes meds
  3. Interacts with antipsychotics, antidepressants
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5
Q

Tx goals for chronic relapse?

A

Treat for as long as it takes and eliminating withdrawal sx

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6
Q

What is the 2 part problem with tobacco dependence?

A
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7
Q

What is the neurotransmitter activity of nicotine?

A

Dopamine: pleasure, appetitie suppression
NE: arousal, appetite suppression
Ach: arousal, cognitive enhancement
Glutamate: learning, memory enhancement
Seratonin: mood modulation, appetite suppression
Endophins” reduction of anxiety, tension, pain
GABA (decrease): reduction in ax, tension, enhance reinforcing effects of nicotine

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8
Q

What are the sx of nicotine withdrawal?

A
  1. Irritability
  2. Ax
  3. Difficulty concentrationg
  4. Restlessness
  5. Depression
  6. Insomnia
  7. Impaired performance
  8. Increased appetite
  9. Craving
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9
Q

What are the approved cessation products?

A
  1. Bupropion
  2. Varenicline
  3. Nicotine patch
  4. Nicotine gum
  5. Nicotine lozenges
  6. Nicotine inhaler
  7. Nicotine nasal spray
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10
Q

What is 2nd line cessation med?

A

Off label: Nortriptyline, clonidine

Nicotine vaccine (under development)

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11
Q

Benefits of using NRT?

A
  1. Improves chances of quitting
  2. Makes indiivduals more comfortable while quitting
  3. Allows consumers to focus changig behaviors
  4. No harmful toxins
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12
Q
A
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13
Q

What are OTC nicotine TX?

A

Pathc: 7mg, 14mg, 21 mg
Gum: 2mg, 4mg
Lozenge: 2mg, 4mg

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14
Q

Prescription nicotine tx?

A

Inhaler and nasal spray

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15
Q

What are the ADRs of nicotine?

A
  1. HA/N/DZ
  2. Vivid dreams
  3. Insomnia
  4. Application site rx
  5. Oral sores and ulcers
  6. nasal tract inrritation
  7. Diarrhea
  8. Dyspepsia
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16
Q

CI of nicotine cessation?

A
  1. Arrhythmia
  2. Unstable angina
  3. Pregnancy (safe)
  4. Uncontrolled HTN
  5. COPD (inhaler)
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17
Q

DDI of nicotine tx?

A
  1. Buproprion SR (unlikely)
  2. Caffeine increases metabolism
  3. Insulin
  4. Antipsychotics
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18
Q

Counseling for nicotine patch?

A
  1. Absorbed in skin
  2. Can take up to 6H to reach peak
  3. Wear above waist, non hairy
  4. DOn’t cut
  5. Wear and reapply Q24H
  6. ADR: JA, N, DZ, skin irritation at site
  7. Don’t apply heat
  8. Remove if undergoing radiological procedures
  9. Apply upon waking
  10. Move patch each day to reduce ADR
  11. Can remove at night if bothersome
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19
Q

Advantages of using pathces?

A
  1. OTC
  2. Best adherence
  3. Less control over situational craving
20
Q

Dosing recommendations for patches

A

Clients who smoke 1PPD: Step 1 (21mg)
Clients who smoke ½ PPD: Step 2 (14 mg
Clients who smoke < ½ PPD: Step 3 (7mg)

Patient remains on each step for 6 weeks before stepping down
General rec: 1mg NRT per cig smoked
* For heavy smokers: 20-39 cpd: 21-42mg

21
Q

How long does patch tx last?

A

Minimum 10-12 weeks, consider longer

22
Q

Considerations f using nicotine gum?

A
  1. Many flavors
  2. Not a good choice for people with jaw problems, braces, retainers, dentures, and dental work
  3. Irritate mouth and throat -> dryness
23
Q

Counseling of nicotine gum?

A
  1. Chew few times and park
  2. Good for irregular smokers
  3. Chewing too much or too fast increases S/E’s
  4. No eating/drinking 15 min before or during use
24
Q

Dosing of gum?

A
  • 1 piece x 1-2 hr
  • Can use 24 pieces/day
  • 12 weeks recommneded, can go longer or reduce over few weeks
25
Counseling for lozenge?
1. Moisten then “park” between cheek and gum line 2. Sugar free 3. May irritate mouth and throat -> dryness 4. No eating / drinking 15 min before or during use 5. Good for ‘irregular’ smokers Yields higher nicotine delivery relative to gum
26
Dosing of lozenge
1 lozenge x at least 8-10/day Up to 20 per day Standard course = 12 weeks
27
When do you use 2mg over 4mg?
**2mg:** Iff you smoke more than 30 min after waking **4mg:** if smoke within 30 min of waking
28
What do combo NRT regimens look like?
29
Considerations for nicotine inhalers?
1. Absorbed through lining of mouth 2. Mimics hand-to-mouth action of smoking (script only) 3. May irritate the mouth and throat and cause dryness if not used properly
30
Dosing of nicotine inhalers?
1. 6-16 cartridges/day 2. 20 min of continuous use 3. Viable for 24H once opened 4. Treat 12 weeks can taper over 6-12 additional weeks 5. Stop use if not abstinent in 4 weeks (monotherapy)
31
Counseling points for inhaler?
1. Inhale into mouth (not lungs), hold, exhale 2. Not inhaler, so use as puffer
32
Considerations of nasal spray?
Nicotrol NS 1. Quick absobtion in lining of nose 2. Largest spike of nicotine 3. Sneezing, sore throat, runny nose and eyes 4. High liability for abuse 5. Good option for highly addicted users 6. Don't inhale while spraying
33
Dosing of nasal sray?
1. Dosage Maximum 40 per day (1 spray in each nostril) 2. Average use = 1dose/hr 3. 100 doses per bottle 4. Standard course is 12 weeks 5. Stop if abstinent in 4 weeks
34
Uses of bupropion SR for cessation?
1. Can be used alone or in combination with NRTs 2. Effective among pts with depressive disorders 3. Non-sedating, activating antidepressant 4. Best suppression on weight gain ADR: HA, insomnia, agitation, dry mouth, shakiness
35
Dosing for Wellbutrin
150mg SR QD x 3 days; 150mg SR BID x 11 weeks **ALt:** 150mg SR QD x 7 days to reduce ‘overstimulation’ S/E’s 1. Quit date at least 14 days 2. Separate dose by 8H 3. Take last dose late afternoon if evidence of sleep disturbnces 4. DC if no progress within 7 weeks
36
Uses of VArenicline for cessation?
1. Reduces the amount of physical and mental pleasure received from tobacco by antagonizing nicotine -> redce crazings and withdrawal 2. Use with NRTs not recommended 3. Dosed in graduating strengths (0.5mg -> 1mg) 4. N andvivid dreams 5. 12 week course, but can be extended
37
Dosing of Varenicline
38
How do you manage insomnia ADR?
**BUP:** separate doses by 8+ hours; last dose no later than 4pm; reduce dose **NRT:** remove patch 1 hour prior to bedtime and replace immediately upon awakening; reduce dose **VAR:** may diminish with time; reduce dose
39
How do manage dry mouth ADR?
**BUP:** usually diminishes with time; reduce dose
40
How do you manage unusual/vivid dream ADR?
**NRT:** often diminishes with time; remove patch 1 hour prior to bedtime **VAR:** may diminish with time; reduce dose
41
How do you manage N ADR?
**VAR:** may diminish over time; reduce dose; treat medicinally
42
How do you manage Jaw Muscle Ache, Hiccups, Nausea?
**GUM:** correct ‘chewing’ technique, alternate form of NRT
43
How do you manage mouth ulcers ADR?
**NRT:** popsicles; steroid injections; *magic mouthwash (MOM/Maalox + liquid benadryl + 2% viscous lidocaine, 1:1:1; shake, swish, spit)
44
How do you manage skin burning and itching ADR?
**TNP:** re-locate switch to alternate NRT
45
How do you manage vmiting ADR?
**VAR:** eat 1st; lower dos
46
Ways we can encourage patients to pursue smoking cessation?
Motivational interviewingq
47
What are the principles for motivational interviewing?
1. Roll with resistance 2. Express empathy 3. Avoid argumentation 4. Develop discrepancy 5. Support self efficacy

Therapeutics III (40 decks)

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