Tobacco Cessation Pharmacology

Question 1

What specific pharmacotherapy considerations are applicable to geriatric patients?

Answer 1

Many comorbidities and meds
Conditions limiting use or administration of medications
Renal impairment
Fall risk with bupropion

Question 2

What specific pharmacotherapy considerations are applicable to patients with COPD?

Answer 2

Theophylline levels may increase with smoking cessation due to decreased enzyme induction
Responsiveness to corticosteroids in patients with asthma may increase with smoking cessation

Question 3

What specific pharmacotherapy considerations are applicable to pregnant and breastfeeding women?

Answer 3

Evidence of human foetal risk with NRT, but smoking risks may outweigh these risks.

Smoking cessation should be encouraged for all
Counselling is first line for pregnancy and breastfeeding
If counselling ineffective, intermittent dosing NRT is preferred over continuous (patch)
Partners, friends, and family should also be offered smoking cessation
Smoke free home environment should be encouraged to avoid exposure to secondhand smoke

Question 4

What specific pharmacotherapy considerations are applicable to clients with mental health disorders and/or concurrent addictions?

Answer 4

Individuals wth mental illnesses are 30-60% more likely to have smoking-related illnesses than individuals without these mental illnesses

Watch for drug interactions
Caution with neuropsychiatric effects with bupropion and varenicline
Symptoms of nicotine withdrawal may be mistaken for symptoms of mental illness

Question 5

What specific pharmacotherapy considerations are applicable to Aboriginal people?

Answer 5

Comorbidities such as DM, mood disorders, renal impairment, alcohol use disorder

Question 6

List contraindications and precautions to NRT.

Answer 6

Contraindications:
Previous acute hypersensitivity reaction
Immediate post-MI period (though I disagree)
Severe or worsening angina
Life-threatening arrhythmia
Recent stroke

Precautions:
Pregnancy
Lactation
Skin disorders (for patch)
Active peptic ulcer disease (for products that involve the mouth)
Bronchospastic disease (for inhaler)

Question 7

How should NRT be dosed for cessation of smokeless tobacco?

Answer 7

[4 mg gum or 4 mg lozenges used]

5 tins per week:
patch 21 mg plus gum or lozenge 1 piece per waking hour
Gum or lozenge alone: 16-20 pieces per day for 8 weeks

Question 8

List common side effects of each type of NRT.

Answer 8

Patch: skin irritation, vivid dreams

Gum or lozenge: mouth/throat soreness, hiccoughs, upset stomach

Inhaler: dry mouth, local irritation of mouth or throat, hiccoughs

Spray: throat irritation, increased salivation, tingling sensation on mouth or lips, hiccoughs

Question 9

Describe bupropion’s mechanism of action.

Answer 9

Inhibits neuronal uptake of serotonin, norepinephrine, and dopamine. MOA in smoking cessation is unknown though.

Question 10

Describe the mechanism of action of varenicline.

Answer 10

Partial agonist of the alpha 4 beta 2 nicotinic acetylcholine receptor.

Question 11

Which combinations of pharmacotherapy are approved?

Answer 11

Two forms of NRT
NRT + bupropion
Bupropion + varenicline

Question 12

List the drug interactions that can result from smoking cessation.

Answer 12

Reduced metabolism induction of CYP 1A1, 1A2, and 2E.