Therapeutics: Smoking Cessation

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Author:
kyleannkelsey
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268310
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Therapeutics: Smoking Cessation
Updated:
2014-04-13 22:49:57
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Therapeutics Smoking Cessation
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Therapeutics: Smoking Cessation
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Therapeutics: Smoking Cessation
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  1. Smoking is # ______ cause of preventable death.
    1
  2. Dependence
    Needs of a substance for homeostasis. Stopping = withdrawal
  3. Addiction
    Compulsive drug seeking behavior, often for non-medical
  4. Tolerance
    Becomes less effective
  5. Reward
    Positive feelings
  6. Reinforcement
    Good feelings should be repeated = Target of Nicotine cessation
  7. 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
  8. When are smoker’s as healthy as people who never smoked?
    Never
  9. Cessation benefits after 20 min:
    BP, HR, extremities temp
  10. Cessation benefits after 8 hours:
    Carbon monoxide, P02, Breath
  11. Cessation benefits after 24 hours:
    MI risk ↓
  12. Cessation benefits after 48 hours:
    Nerve regeneration, ↑ Smell / taste
  13. Cessation benefits after 72 hours:
    Lung capacity ↑
  14. Cessation benefits after 2 – 3 weeks:
    Circulation ↑, Lung capacity ↑, Walking = easier
  15. Cessation benefits after 1-9 mo:
    Pulmonary ciliary re-grows = ↓congestion/SOB, energy ↑
  16. Cessation benefits after 1 yr:
    CHD risk = ½
  17. Cessation benefits after 2 yr:
    Risk of MI = nearly normal
  18. Cessation benefits after 5 yrs:
    GI & Lung cancer = ½, Stroke risk ↓
  19. Cessation benefits after 10 yrs:
    Lung cancer risk = nearly normal
  20. Patient Assessment techniquies:
    • 5As
    • 5Rs
    • SMART
  21. What are the 5A’s:
    Ask, Advise, Assess, Assist, Arrange
  22. If a patient expresses that they Want to quit during 5A’s, what next?
    SMART
  23. If a patient expresses that Don’t want to quit, what next?
    5 R’s
  24. What are the 5R’s:
    Relevance, Risk, Rewards, Roadblocks (most important thing to talk about), Repetition
  25. What does SMART stand for?
    Set a date, Talk for support, Anticipate obstacles, Remove triggers, Talk to provider
  26. 1 cig = how much nicotine?
    1-3 mg nicotine (some report up to 4-6 mg)
  27. Major difference between 1st and 2nd line drugs =
    Safety concerns with 2nd line (NOT FDA approved)
  28. 1st line therapies for cessation:
    NRT (first choice), Bupropion, Varenicline
  29. 2nd line therapies for cessation:
    Clonidine, Nortriptyline
  30. 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
  31. 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
  32. How do you discard an NRT patch?
    Discard by folding and placing in pouch
  33. 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
  34. NRT gum is CI/NR in:
    Stomach ulcers, diabetes, >24/day, acid during or 15 min before
  35. 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
  36. 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
  37. 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)
  38. NRT inhlaler (Nicotrol) dosing:
    • 6 cartidges/first 3-6 weeks
    • Max: 16 cart/day x12 wks
    • (1 cart = 1 cig)
  39. When should you D/C inhaler?
    • hasn’t stopped smoking by 4 weeks
    • Reverts back to smoking, cold/congestion
  40. Wat special benefit might the NRT inhaler provide?
    Provides ritual comfort
  41. What are the CIs for NRT NS (Nicotrol NS)
    Don't use on skin, eyes and mouth, cold/congestion
  42. NRT nasal spray (Nicotrol NS) has how many doses per vial?
    vial = 100 doses/200 sprays
  43. 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
  44. What is the MOA for Bupropion (Zyban)?
    Inhibits NOR and DA uptake = enhances ability to abstain
  45. Bupropion (Zyban) is 1st or 2nd line?
    1st line
  46. 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
  47. 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
  48. 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
  49. Varenicline (Chantix) is a first or second line drug?
    1st line non-nicotine
  50. 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)
  51. What is the MOA of Varenicline (Chantix)?
    Prevents nicotine binding to receptor, partial DA agonist = Lessens cravings
  52. Varenicline (Chantix) is CI/NR in:
    past or present psychosis, CVD = may cause adverse effects
  53. What are the common AE’s for Varenicline (Chantix)?
    Neuropsychosis or sleepiness
  54. Clonidine is a 1st or 2nd line therapy?
    2nd line (b/c SE’s)
  55. What is CI in Clonidine?
    Abrupt discontinuation CI= nervous, agitated, HA< tremor, rapid ↑BP ( biggest issue)
  56. 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
  57. What are the Common SE’s for Clonidine?
    • Dry mouth, Drowsiness, Sedation, Constipation, Hypotension, Rebound HTN
    • Potent Alpha agonist
  58. Nortriptyline is a 1st or 2nd line therapy?
    • 2nd line
    • FDA: not evaluated for smoking cessation
  59. 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.
  60. When should you caution use of Nortriptyline?
    CV disease, Concomitant use with MAOIs (requires 2 week wash out)
  61. 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
  62. Alternative Combos: 1st and 2nd line are:
    • NRT patch + Nortriptyline
    • NRT patch + 2nd gen antidepressant (Paroxitine or Venlefaxine)

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