Tobacco Cessation Flashcards
Nicotine: Pharmacodynamics
- Rapidly absorbed
- Acts on nicotine receptors in brain and CNS
- Each puff maintains nicotine blood levels
- Development of tolerance
- Withdrawal syndrome if discontinued
Goals of Treatment
- Complete discontinuation of tobacco use
- Nicotine replacement therapy
- – Gradual, controlled reduction of nicotine to avoid withdrawal symptoms
- Bupropion (Zyban)
- – Tobacco-free by 7 to 12 weeks of therapy
- Varenicline (Chantix)
- – Tobacco-free by 12 weeks
Rational Drug Selection
Nicotine replacement therapy
Antidepressant
- Bupropion
Nicotine receptor partial agonist
- Varenicline
Nicotine Replacement Therapy
- Used in patients who smoke more than 20 cigarettes per day
- OTC
- –Gun: Nicorette
- –Patch: Nicotrol, Nicoderm, Habitrol
- –Lozenges: Commit
- Prescription drugs
- –Nasal spray: Nicotrol NS
- –Inhaler: Nicotrol
- E-cigarettes not recommended
Nicotine Replacement Therapy: Precautions and contraindications
Pregnancy
- Gum: Category C
- Transdermal patch: category D
Contraindicated
- immediately after a MI
- immediately after a stroke
Nicotine Gum: Pharmacodynamics
- Improves cessation success
- Buccal absorption
- Need to follow direction or nicotine will release too quickly, increasing ADRs
- More than 25 cigarettes per day: use states at 4 mg every hour
- Less than 25 cigarettes per day: used 2 mg every hour
- Patients weaned off medication after 2 to 3 months of nicotine abstinence
Nicotine Lozenge: Pharmacodynamics
- Lozenge slowly dissolves in mouth
- Patient is advised not to chew lozenge
- Dose is 1 lozenge every 1-2 hours
- Patients should use 4 mg if smoking within 30 minutes of waking
- Patient should not eat or drink while lozenge is in mouth
- Wean after 6 weeks of nicotine abstinence
Nicotine Patch: Pharmacodynamics
- Transdermal absorption
- 16-hour and 24-hour patches
- Slow onset, steady state once at peak
- Dose of patch determined by number of cigarettes the patient smokes per day
- Patch dose decreased gradually
- Patient cannot smoke while using patch
- ADRs: nicotine toxicity
- Advice about disposing of patches safely
Nicotine Nasal Spray: Pharmacodynamics & Patient Education
Intranasal administration
Rapid onset and peak
Patient Education
- Proper administration
- ADRs
Abuse potential
Nicotine Inhaler: Pharmacodynamics & ADRs
Inhaled drug
Puffs on inhaler for 20 minutes
Dose titrated down gradually over 12 weeks
ADRs:
- Cough
- Mouth irritation
- Dyspepsia
E-CIgarettes: Pharmacodynamics
Battery-operated devices
Inhaled nicotine
Used by some to help with nicotine withdrawal when stopping smoking
Studies on safety needed because of potential toxic inhalants
Anti-depressants
Bupropion (Zyban)
Unknown action in smoking cessation
Started 1-2 weeks before quit date
- Dose: 150 mg daily for 3 days
- Then increased to 150 mg twice daily
Quit day
- Cold turkey
- Ok to use nicotine replacement product
Therapy continued for 7-12 weeks, may be longer, if needed
Bupropion (Zyban): Precautions & Contraindications
- Seizure disorders, bulimia, and anorexia nervosa
- Neurological disorders
- Reduced dose in renal dysfunction
- Avoid in pregnancy
- Not prescribed with Wellbutrin
Bupropion (Zyban): ADRs
Insomnia (40%)
Dizziness (10%)
Dry mouth (10%)
Nicotinic Receptor Partial Agonists: Pharmacodynamics & Dosing
- Varenicline (Chantix)
- Highly selective to the alpha-4-beta-2 and moderately selective to the 5-HT3 receptor
- Started a week before quit date
- Dosing: 0.5 mg orally daily for the first 3 days
- –Then 0.5 mg twice daily on days 4-7
- –On day 8, increased to 1.0 mg twice daily
- Therapy continued for 12 weeks
Varenicline (Chantix): ADRs and Precautions
ADRs
- Nausea: 16-41%
- Neuropsychiatric symptoms
- – Changes in behavior, agitation, depressed mood, suicidal ideation, and actual suicide behavior
Pregnancy category C: Should not be used in pregnancy
Adult use only (18 years or older)
Alpha2 Adrenergic Agonists
Clonidine: Second-line treatment
Used for patients who refuse or cannot tolerate first-line therapy
Use of tablets or patch
Combination Therapy
Agency for Health Care Policy and Research Smoking Cessation: Clinical Practice Guidelines
Level A evidence for:
- Long-term (greater than 14 weeks) nicotine patch + other nicotine replacement therapy (gum and spray)
- Nicotine patch + nicotine inhaler
- Nicotine patch + bupropion - sustained-release
Non-pharmacological Treatment of Nicotine Addiction
- Individual or group counseling
- Support via telephone hot line or internet support group
- Interventions: problem solving, skills, training, relapse prevention, and stress management
Patient Variables
Pregnancy
- Nicotine replacement products not recommended
- Bupropion (Zyban) not recommended
- Varenicline (Chantix) not recommended
Children- not used
Adolescents
- Early identification and support for quitting
- Some evidence for use of patch (prescription needed)
Monitoring
- Withdrawal symptoms
- Nicotine toxicity
- ADRs
- Neuropsychiatric changes monitored in patients on varenicline
Patient Education
Proper dosing
- Removal of patch at appropriate time
- Proper dosing of gum and inhaler
Advice on OTC products
Monitoring of ADRs
