Therapeutics: Smoking Cessation
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Smoking is # ______ cause of preventable death.
Needs of a substance for homeostasis. Stopping = withdrawal
Compulsive drug seeking behavior, often for non-medical
Becomes less effective
Good feelings should be repeated = Target of Nicotine cessation
Pathway of Nicotine in the brain:
- Binds Nicotine/ACH receptors of VTA → DA released by VTA → Da binds receptors of NAc
- Last step = reward = reinforces behavior
When are smoker’s as healthy as people who never smoked?
Cessation benefits after 20 min:
BP, HR, extremities temp
Cessation benefits after 8 hours:
Carbon monoxide, P02, Breath
Cessation benefits after 24 hours:
MI risk ↓
Cessation benefits after 48 hours:
Nerve regeneration, ↑ Smell / taste
Cessation benefits after 72 hours:
Lung capacity ↑
Cessation benefits after 2 – 3 weeks:
Circulation ↑, Lung capacity ↑, Walking = easier
Cessation benefits after 1-9 mo:
Pulmonary ciliary re-grows = ↓congestion/SOB, energy ↑
Cessation benefits after 1 yr:
CHD risk = ½
Cessation benefits after 2 yr:
Risk of MI = nearly normal
Cessation benefits after 5 yrs:
GI & Lung cancer = ½, Stroke risk ↓
Cessation benefits after 10 yrs:
Lung cancer risk = nearly normal
Patient Assessment techniquies:
What are the 5A’s:
Ask, Advise, Assess, Assist, Arrange
If a patient expresses that they Want to quit during 5A’s, what next?
If a patient expresses that Don’t want to quit, what next?
What are the 5R’s:
Relevance, Risk, Rewards, Roadblocks (most important thing to talk about), Repetition
What does SMART stand for?
Set a date, Talk for support, Anticipate obstacles, Remove triggers, Talk to provider
1 cig = how much nicotine?
1-3 mg nicotine (some report up to 4-6 mg)
Major difference between 1st and 2nd line drugs =
Safety concerns with 2nd line (NOT FDA approved)
1st line therapies for cessation:
NRT (first choice), Bupropion, Varenicline
2nd line therapies for cessation:
CI/not recommended for NRT:
Pregnant (category D), CV disease (2 weeks post-MI, arrhythmias, unstable angina), using other nicotine, continued tobacco use, cut patch, wearing >1 patch, MRIs, hairy sites w/ patch
NRT patch Dose:
- Step 1 = 21 mg (1-6 wk)
- Step 2 = 14 mg (7-8 wk)
- Step 3 = 7 mg (9-10 wk)
- 8-10 wks max, 16-24 hours at a time
- >10 cigs/day = Step 1
- < 10 cigs/day = Step 2 for 6 wk → Step 3 for 2 wk
How do you discard an NRT patch?
Discard by folding and placing in pouch
NRT gum, how do you use:
- Chew slowly, stop w/ pepper taste or tingle, hold btw cheek and gum, chew when fades
- NRT gum Dose:
- > 25 cigs/day = 4mg < 25 cigs/day = 2mg 1 gum lasts ~30 min
- 1 Q1-2H (1-6 wk) → 1 Q2-4H (7-9 wk) → 1 Q4-8H (10-12 wk)
- >9/day weeks 1-6 = greater success
NRT gum is CI/NR in:
Stomach ulcers, diabetes, >24/day, acid during or 15 min before
NRT lozenge (Commit), how do you select a dose?
- cig w/in 30 min of waking = 4mg
- cig after 30 min of waking = 2 mg
NRT lozenge (Commit) Dose:
- 1 Q1-2H (1-6 wk)
- 1 Q2-4H (7-9 wk)
- 1 Q4-8H (10-12 wk)
- Same as gum
What should you not do when taking NRT gum?
- NMT 20/day or 5/6hr
- No food/drink 15 min before or during
- > 9 pieces/day for 1st 6 weeks
- Don’t chew or swallow
- move side-to side and completely dissolve
- (CI/NR same as gum)
NRT inhlaler (Nicotrol) dosing:
- 6 cartidges/first 3-6 weeks
- Max: 16 cart/day x12 wks
- (1 cart = 1 cig)
When should you D/C inhaler?
- hasn’t stopped smoking by 4 weeks
- Reverts back to smoking, cold/congestion
Wat special benefit might the NRT inhaler provide?
Provides ritual comfort
What are the CIs for NRT NS (Nicotrol NS)
Don't use on skin, eyes and mouth, cold/congestion
NRT nasal spray (Nicotrol NS) has how many doses per vial?
vial = 100 doses/200 sprays
How is the NRT NS (Nicotrol NS) used?
- Prime w/ 1st use or >24 hrs since last use
- Blow nose → Tilt head back → insert tip → 1 spray each nostril
What is the MOA for Bupropion (Zyban)?
Inhibits NOR and DA uptake = enhances ability to abstain
Bupropion (Zyban) is 1st or 2nd line?
How should you dose Bupropion (Zyban)?
- Start 1-2 weeks before quit date → 150 mg QD x3D → 150mg BID or 300mg QD for 7-12 weeks
- Long term = 150 mg QD up to 6 mo.
- Max: 300 mg QD
If a patient has Insomnia when taking Bupropion (Zyban), what should you do?
If taking 150 BID: take 2nd dose in afternoon > 8hrs after first
What are the CIs for Bupropion (Zyban)?
- Past or present psychosis, behavior changes, pregnancy (C), HTN, insomnia, Dry mouth
- BB warning: SEIZURE, eating disorders, MAO inhibitors in past 2 wks
Varenicline (Chantix) is a first or second line drug?
1st line non-nicotine
How do you dose Varenicline (Chantix)?
- 0.5 mg QD 1-3 days →
- 0.5 BID 4-7 days →
- 1 mg BID day 8 – 12 wks
- (Can last extra 12 weeks)
What is the MOA of Varenicline (Chantix)?
Prevents nicotine binding to receptor, partial DA agonist = Lessens cravings
Varenicline (Chantix) is CI/NR in:
past or present psychosis, CVD = may cause adverse effects
What are the common AE’s for Varenicline (Chantix)?
Neuropsychosis or sleepiness
Clonidine is a 1st or 2nd line therapy?
2nd line (b/c SE’s)
What is CI in Clonidine?
Abrupt discontinuation CI= nervous, agitated, HA< tremor, rapid ↑BP ( biggest issue)
How should you dose Clonidine?
- 3-12 week treatment
- PO: Start on quit date → 0.1 mg BID → taper down by 0.1-0.2 mg QD
- Patch: Start 2-3 days prior to quit → 0.1-0.2 mg QD → taper down by 0.1 mg QD
What are the Common SE’s for Clonidine?
- Dry mouth, Drowsiness, Sedation, Constipation, Hypotension, Rebound HTN
- Potent Alpha agonist
Nortriptyline is a 1st or 2nd line therapy?
- 2nd line
- FDA: not evaluated for smoking cessation
How should you dose Nortriptyline?
Start 10-28 days before quit → 25 mg QD → increase to 70-100 mg QD → upt o 12 wks or 6 mo.
When should you caution use of Nortriptyline?
CV disease, Concomitant use with MAOIs (requires 2 week wash out)
What are the 1st line Combo therapies?
- NRT patch w/ gum/lozenge/spray for > 14 weeks (long term)
- NRT pacth + inhaler
- NRT patch + bupropion SR = ONLY COMBO FDA APPROVED
Alternative Combos: 1st and 2nd line are:
- NRT patch + Nortriptyline
- NRT patch + 2nd gen antidepressant (Paroxitine or Venlefaxine)
What would you like to do?
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