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Notes/Facts/Brand vs Generic > Tobacco Cessation > Flashcards

Tobacco Cessation Flashcards

1
Q

Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A
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2
Q

___________ is the leading cause of preventable death in the US and known modifiable risk factor for heart disease, stroke, pregnancy complications, COPD, multiple cancers and many other diseases.

In some cases, disease risk (e.g. lung cancer) is related to an individuals _____________ which can be calculated using the formula ____________

A

smoking

pack-year smoking history

“pack-year smoking hx” = [cigarette packs per day] x [ number of years smoked]

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3
Q

tobacco dependence is a chronic disease that often requires ___________

It is essential for healthcare providers to ask patients ______________

A

repeated interventions & multiple attempts to quit

about tobacco use, (use the 5 As Model)

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4
Q

The 5 A’s Model:

-
-
-

A
  • Ask about tobacco use
  • Advise to quit
  • Assess willingness to make a quit attempt
  • Assist in quit attempt
  • Arrange follow-up

“a national network of tobacco quit lines is available by telephone for patients at 1-800-QUIT-NOW (1-800-784-8669)”

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5
Q

Counseling is an important component of tobacco cessation treatment, and two methods that are especially effective are __________ and ___________.

A

behavioral counseling (problem-solving skills training)

social support

There is a strong correlation between counseling intensity (length and number of counseling sessions) and quitting success.

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6
Q

_________ should be encouraged for all patients attempting to quit, except when medically contraindicated!!

___________ reduce withdrawal symptoms, including anxiety, irritability, depression, insomnia, poor concentration, restlessness, increased appetite and an urge to smoke (cravings).

A

medications

medications

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7
Q

The combination of __________ and __________ is more effective than using either alone.

A

counseling

medications

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8
Q

There are several effective, first-line options:

A
  • Five (NRTs) nicotine replacement therapies: patch, gum, lozenge, inhaler or nasal spray
  • two non-nicotine drugs: bupropion and varenicline

combining two drugs, such as a long-acting nicotine patch with a short acting NRT product or a nicotine patch with bupropion SR is effective and can be used first line

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9
Q

There is a strong link between vitamin E acetate exposure and the outbreaks of e-cigarette, or vaping, product-use associated lung injury (_______)

A

EVALI

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10
Q

Due to health concerns, e-cigarettes are _______________ for smoking cessation.

A

NOT Recommended

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11
Q

Treatment Guidelines Recommend
- behavioral counseling over drugs for several patient populations including: __________________

A
  • pregnant women
  • adolescents (generally person’s less than 18 years of age)
  • smokeless tobacco users (chewing tobacco)
  • light smokers ( < less than 10 cigarettes a day)
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12
Q

The non-nicotine chemicals in tobacco smoke induce CYP enzymes, primarily _________

A

CYP1A2

induction, leads to more enzyme being available & active, to metabolize substrates. So we get decreased levels of substrates.

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13
Q

Smokers who quit no longer have CYP1A2 induction and as a result, can experience side effects from _____________

A

supratherapeutic levels of caffeine, theophylline, R-isomer of warfarin.

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14
Q

Women > or = to 35 years of age who smoke should NOT ___________________

A

take estrogen-containing oral contraceptives due to increased risk of cardiovascular events.

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15
Q

Smokers aged 19 - 64 years should receive a vaccine for ____________ and ________

A
  • pneumococcal vaccine (PPSV23 Pneumovax 23, PCV15 Vaxnuvance, PCV20 Prevnar 20)
    1 dose of PCV20
    OR
    1 dose of PCV15 then –> 1 dose PPSV23 in one year
  • an annual influenza vaccine
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16
Q

what is the pack-year smoking history for a 55-year-old female who has smoked 1.5 packs per day for the past 35 years?

A

52.5 pack years

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17
Q

Treatment option:

Behavior counseling-

A

-social support
-behavioral

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18
Q

major pathway and neurotransmitters implicated in tobacco use disorder:

A
  • the dopamine reward pathway plays an important role in the tobacco use disorder
  • nicotine and other chemicals modulate the brain reward system by activating Nicotinic receptors, which leads to an increase in Dopamine release.
  • dopamine regulates emotional, and motivational behavior and activates our reward system.
  • Norepinephrine release is also triggered by nicotine which leads to an enhanced reward response. Similar to dopamine.
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19
Q

(NRT) Nicotine Replace Therapy
- there are OTC options & options available with a Rx prescription

A
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20
Q

IF NRT is selected as initial therapy for tobacco cessation, then combining ______________ is most effective.

A

two NRTs dosage forms

one long acting & 1 short acting

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21
Q

Which NRT therapies are long-acting?

A

patch

22
Q

Which NRT therapies are short acting?

A

gum
lozenge

23
Q

Which NRT options require a prescription for use?

A

Nicotrol = nicotine inhaler

Nicotrol NS = nicotine nasal spray

the nicotine inhaler & nicotine nasal spray require prescriptions, everything else is available OTC

24
Q

How do you dose for the nicotine patch?

What is the magical number “cut point” of cigarettes per day?

What are the week schedule intervals for patch?

A

**Dosing is based on the number of cigarettes per day s

10

Does the patient smoke more than 10 cigarettes per day?
_
Yes, so starting dose is 21mg once daily for 6 weeks, then 14mg once daily for 2 weeks, then 7mg once daily for 2 weeks.

Does the patient smoke more than 10 cigarettes per day?
No

25
Q

How do you dose for the nicotine gum or lozenge?

What is the “cut point” number for the timing of the first cigarette per day?

What week schedule interval do the gum/lozenge follow?

A

**Dosing is based on the timing of the first cigarette of the day upon awakening

30 minutes

Does the patient smoke there first cigarette in 30 minutes or less upon awakening?
Yes, so starting dose is 4mg every 1-2 hours for 6 weeks (> or = to 9 pieces per day for 6 weeks), then 4mg every 2-4 hours for 3 weeks, then 4mg every 4-8 hours for 3 weeks.

Does the patient smoke there first cigarette in 30 minutes or less upon awakening?

No, so starting dose is 2mg every 1-2 hours for 6 weeks (> or = to 9 pieces per day for 6 weeks), then 2mg every 2-4 hours for 3 weeks, then 2mg every 4-8 hours for 3 weeks

26
Q

How do you dose the nicotine inhaler or nasal spray?

A

Dosing is on an as needed basis and should be individualized per patient based on nicotine needs.

  • up to 6 months for the inhaler
  • up to 3 months for the nasal spray
27
Q

How many cigarettes are in 1 pack?

A

20 cigarettes per pack

28
Q

NicoDerm CQ

Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes: OTC
Drug-Drug/Food interactions:

  • concern is around safety since nicotine has vasoconstrictive properties
A

nicotine patch

Class:

Indications: Smoking Cessation

MOA:

Dosage forms:
If smoking more than 10 cigarettes per day:
21mg/14mg/7mg —> week schedule 6weeks/2weeks/2weeks (10weeks total)

If smoking 10 cigarettes or less than 10 cigarettes per day:
14mg/7mg —-> week schedule 6weeks/2weeks (8 weeks total)

Dosing: **Dosing is based on the number of cigarettes per day

Max dose:

Contraindications:

Warnings:
- **Avoid in immediate post-MI period, life threatening arrhythmias, severe or worsening angina and pregnancy

Side Effects:
- ** Insomnia, nervousness, headache, dizziness, dyspepsia
-*patch: vivid dreams, skin irritation

Monitoring:

Pearls/Notes:
-*Patch: highest adherence rate; remove before an MRI
- *long-acting dosage form
- * The FDA prohibits sale of nicotine products to individuals < than 18 years of age; identification required for purchase
- *Combination therapy with the patch and short-acting NRT ( gum or lozenge) to reduce cravings is MOST effective.

Drug-Drug/Food interactions:

29
Q

Nicorette

Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes: OTC
Drug-Drug/Food interactions:

A

nicotine gum (sugar free)

Class:

Indications: Smoking Cessation

MOA:

Dosage forms: 4mg/2mg

Dosing: **Dosing is based on the timing of the first cigarette of the day upon awakening

Does the patient smoke there first cigarette in 30 minutes or less upon awakening?

Yes,
Starting dose:
4mg every 1-2 hours for 6 weeks (> or = to 9 pieces per day for 6 weeks), 4mg every 2-4 hours for 3 weeks, then
4mg every 4-8 hours for 3 weeks.

Does the patient smoke there first cigarette in 30 minutes or less upon awakening?

No,
Starting dose:
2mg every 1-2 hours for 6 weeks (> or = to 9 pieces per day for 6 weeks), 2mg every 2-4 hours for 3 weeks, then
2mg every 4-8 hours for 3 weeks

Max dose:

Contraindications:

Warnings:
- **Avoid in immediate post-MI period, life threatening arrhythmias, severe or worsening angina and pregnancy

Side Effects:
- ** Insomnia, nervousness, headache, dizziness, dyspepsia

Monitoring:

Pearls/Notes:
- * The FDA prohibits sale of nicotine products to individuals < than 18 years of age; identification required for purchase
- short-acting dosage form
-*(sugar free): the 4mg strength can reduce or delay weight gain; acidic beverages/foods decrease buccal absorption, do NOT eat/drink 15 minutes before or during use
-minimum duration 12 weeks

Drug-Drug/Food interactions:

30
Q

Nicorette Mini

Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes: OTC
Drug-Drug/Food interactions:

A

nicotine lozenge (sugar free)

Class:

Indications: Smoking Cessation

MOA:

Dosage forms:

Dosing: **Dosing is based on the timing of the first cigarette of the day upon awakening
Max: 20 lozenges/day, 5 lozenges per 6 hours

Does the patient smoke there first cigarette in 30 minutes or less upon awakening?

Yes,
Starting dose:
4mg every 1-2 hours for 6 weeks (> or = to 9 pieces per day for 6 weeks), 4mg every 2-4 hours for 3 weeks, then
4mg every 4-8 hours for 3 weeks.

Does the patient smoke there first cigarette in 30 minutes or less upon awakening?

No,
Starting dose:
2mg every 1-2 hours for 6 weeks (> or = to 9 pieces per day for 6 weeks), 2mg every 2-4 hours for 3 weeks, then
2mg every 4-8 hours for 3 weeks

Max dose:

Contraindications:

Warnings:
- **Avoid in immediate post-MI period, life threatening arrhythmias, severe or worsening angina and pregnancy

Side Effects:
- ** Insomnia, nervousness, headache, dizziness, dyspepsia

Monitoring:

Pearls/Notes:
- * The FDA prohibits sale of nicotine products to individuals < than 18 years of age; identification required for purchase
- short-acting dosage form
-*(sugar free): the 4mg strength can reduce or delay weight gain; acidic beverages/foods decrease buccal absorption, do NOT eat/drink 15 minutes before or during use
-minimum duration 12 weeks

Drug-Drug/Food interactions:

31
Q

Nicotrol

Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

nicotine inhaler

Class:

Indications: Smoking Cessation

MOA:

Dosage forms:

Dosing:
6-16 cartridges daily for up to 3 months, then taper frequency of use over 3 months or less

Max dose:

Contraindications:

Warnings:
- **Avoid in immediate post-MI period, life threatening arrhythmias, severe or worsening angina and pregnancy
- ** Avoid in Asthma, COPD, and other chronic respiratory diseases

Side Effects:
- ** Insomnia, nervousness, headache, dizziness, dyspepsia
-* inhaler: mouth and throat irritation, cough, rhinitis

Monitoring:

Pearls/Notes:
- * The FDA prohibits sale of nicotine products to individuals < than 18 years of age; identification required for purchase
- short-acting dosage form
- mimics the hand to mouth smoking action, providing a coping mechanism

Drug-Drug/Food interactions:

32
Q

Nicotrol NS

Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

nicotine nasal spray

Class:

Indications: Smoking Cessation

MOA:

Dosage forms:

Dosing:
*[1 dose = 1 spray in each nostril]
Use 1-2 doses per hour, increase as needed for symptom relief.
Min: 8 doses/day
Max: 5 doses/hr or 40 doses/day
*Use for up to 3 months.

Max dose:

Contraindications:

Warnings:
- **Avoid in immediate post-MI period, life threatening arrhythmias, severe or worsening angina and pregnancy
- ** Avoid in Asthma, COPD, and other chronic respiratory diseases

Side Effects:
- ** Insomnia, nervousness, headache, dizziness, dyspepsia
- *nasal spray: nasal irritation, watery eyes, sneezing, transient changes in taste and smell

Monitoring:

Pearls/Notes:
- * The FDA prohibits sale of nicotine products to individuals < than 18 years of age; identification required for purchase
- short-acting dosage form
- *nasal spray: fastest delivery and is useful for rapid relief of withdrawal symptoms; has the highest risk of dependence.

Drug-Drug/Food interactions:

33
Q

Zyban*

Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

bupropion SR

Class:

Indications: Smoking Cessation

MOA: blocks neuronal reuptake of dopamine and/or norepinephrine resulting in reduced cravings and other withdrawal symptoms.
*[blocks reuptake of DA & NE]

Dosage forms: tablet 100/150/200mg

Dosing: ** Start at least 1 week before quit date**
SR: 150mg once daily in the morning for 3 days, then 150mg BID. Use for up to 6 months

Max dose: 300mg/day

Boxed Warnings:
* Increased risk of suicidal thinking and behavior in children, adolescents and young adults taking antidepressants

Contraindications:
*Seizure disorder; *history of anorexia/bulimia; *concurrent use with MAO inhibitor, *linezolid or *IV methylene blue; abrupt discontinuation of ethanol or sedatives

Warnings:
*Serious neuropsychiatric events (mood changes, hallucinations, paranoia, aggression, anxiety)
activation of mania/hypomania, hypertension, angle-closure glaucoma, rash (including SJS)

Side Effects: *Dry mouth, *insomnia, *tremors, *weight loss, agitation, anxiety, tachycardia, headache, sweating

Monitoring:

Pearls/Notes:
** Started before the QUIT date
- DO NOT need to be tapered when discontinued
-*brand name discontinued, but used to distinguish the use of 12-Hour formulation
- patients should be treated for a minimum of 3 months (12-weeks) but can be treated for up to 6 months to prevent relapse.
-Do NOT use with other forms of bupropion
- Delays weight gain
- To decrease insomnia, take the first dose upon awakening and the 2nd dose 8 hours after the first dose. If no significate progress by week 7, consider discontinuation.
- *Med Guide required
- inhibits reuptake of DA & NE which plays a role in satiety and appetite due to its stimulate effects.

Drug-Drug/Food interactions:

34
Q

Which bupropion is indicated and approved for smoking cessation?
- Aplenzin
- Forfivo XL
- Wellbutrin SR
- Wellbutrin XL
- Zyban

A

Zyban **

all other options are approved for depression or seasonal affective disorder.

35
Q

Chantix

Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

varenicline

Class:

Indications: Smoking Cessation

MOA:
medication reduces withdrawal symptoms by acting as a partial neuronal alpha-4 beta-2 nicotinic receptor agonist. With vareniclines high binding affinity to receptor, it blocks nicotine from binding to nicotinic receptor. Since medication is also a partial agonist it reduces cravings.

drug is a partial neuronal alpha-4 beta-2 nicotinic receptor agonist. It causes low-level stimulation of the receptor while blocking the ability of nicotine to bind. This relieves symptoms of nicotine withdrawal and inhibits the surges of dopamine responsible for the reinforcement and reward associated with smoking.

Dosage forms: 0.5/1mg tablet

Dosing: ** Start at least 1 week before quit date**
Days 1-3: 0.5mg once daily
Days 4-7: 0.5mg BID
Day 8 (QUIT Date) and beyond: 1mg BID

If CrCl < 30mL/min: then 0.5mg daily titrated to MAX of 0.5mg BID

Use for 3 months; can use for another 3months to maintain success

Max dose:

Boxed Warnings:

Contraindications:

Warnings: *Serious neuropsychiatric events (agitation, depression, suicidal thoughts/behaviors), seizures, increases effects of alcohol,
somnambulism (sleepwalking)

Side Effects: *nausea (~30%, dose dependent), *insomnia, *abnormal dreams, *headache

Monitoring:

Pearls/Notes:
** Started before the QUIT date
- DO NOT need to be tapered when discontinued
- * To decrease nausea. take after eating with a full glass of water; can reduce dose if needed
-* to decrease insomnia, take 2nd dose earlier than bedtime
- ** Efficacy has NOT been demonstrated in those < or = to 16 years of age (Drug NOT Recommended in population)
- *if unable to quit abruptly ib day 8, decrease smoking by 50% in the first 4 weeks, an additional 50% in weeks 5-8, with complete cessation by week 12
- *Med Guide required

Drug-Drug/Food interactions:

36
Q

what forms is chantix available in?

A

Chantix Starting Month Pak: contains 0.5mg tablets (11) & 1mg tablets (42), so 53 tablets total for a 28 day supply.

Chantix Continuing Month Pak: contains 1mg tablets (56 tablets), so for a 28 day supply.

37
Q

Tyrvaya

A

varenicline nasal spray

indicated for dry eyes

38
Q

insomnia, tremors, or nausea are increased side effects if using the nicotine patch in combination with _________

A

chantix or zyban

39
Q

Reasons people started vaping:

A

-stop or reduce tobacco consumption
-vaping is less harmful than tobacco
-
-

40
Q

All smokers should be offered medications unless it is contraindicated, they are pregnant, or they are an adolescent.

A

The combination of the nicotine patch + gum, lozenge or bupropion is more effective than the patch alone.

41
Q

*Treatment considerations for tobacco cessation:

If wanting to delay weight gain, then use _________

A

Gum, lozenge, and bupropion SR

42
Q

*Treatment considerations for tobacco cessation:

if wanting to treat depression, then use __________

A

bupropion SR

43
Q

*Treatment considerations for tobacco cessation:

If patient has dentures, then avoid ________

A

nicotine gum

44
Q

*Treatment considerations for tobacco cessation:

If patient has asthma or COPD, then avoid __________

A

nicotine inhaler or nicotine nasal spray

” inhaled nicotine can cause bronchospasms”

45
Q

*Treatment considerations for tobacco cessation:

If patient has a skin condition, then avoid ______

A

nicotine patch

46
Q

*Treatment considerations for tobacco cessation:

If patient has seizures, then avoid _______

A

bupropion & varenicline

47
Q

Key counseling points for Nicotine Patch:

A
48
Q

Key counseling points for Nicotine Gum:

A
  • chew slowly until there is a tingle or peppery flavor in the mouth
  • park in between the cheek and gum
  • when the tingle or flavor goes away, begin chewing slowly again until it returns, then park the gum again
  • repeat until most of the flavor or tingle is gone (~30 minutes)
  • Do NOT eat or drink for 15 minutes before or during chewing
  • “the gum has been found to reduce weight gain after smoking cessation and correlates to the dose of nicotine replacement therapy being used”. Meaning the higher 4mg dosage form will cause less weight gain than the 2mg dose.
49
Q

Key counseling points for Nicotine Lozenge:

A
  • Do NOT eat or drink for 15 minutes before or during use
  • Do NOT chew or swallow lozenge. Allow it to dissolve slowly.
  • Move the lozenge from one side of the mouth to the other until it has completely dissolved (~20-30 minutes)
  • May cause a warm or tingling sensation (should experience when nicotine is released)
  • Do not use more than one lozenge at a time or continuously use one lozenge after another
50
Q

On average, patients gain 5-10 lbs after they quit smoking.

A

Notes/Facts/Brand vs Generic (23 decks)

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