Pharm Smoking Cessation

Question 1

ID a drug product as nicotine replacement product

Answer 1

Nicotine gum - Nicorette®, Thrive®, Nicorelief®

Nicotine lozenge - Commit®, Nicorette®

Nicotine nasal spray - Nicotrol NS®

Nicotine oral inhaler - Nicotrol®

Question 2

ID the 5 As that clinicians should employ when advising a patient who smokes

Answer 2

• Ask
• Advise
• Assess
• Assist
• Arrange

Question 3

Ask

Answer 3

ask about tobacco use: ID and document status for each patient at each visit

Question 4

Advise

Answer 4

urge every tobacco user to quit

Question 5

Assess

Answer 5

assess the willingness to quit

Question 6

Assist

Answer 6

assist in quit attempts: by providing cessation therapies (behavioral + pharmacotherapy)

Question 7

Arrange

Answer 7

arrange f/u w/i the first week after the quit date to evaluate meds for efficacy and adverse effects

Question 8

• For patients who are unwilling to quit, provide interventions to increase future quit attempts
• this falls under “assist”
• What are the 5 Rs?

Answer 8

• relevant
• risks
• rewards
• roadblocks
• repeat

Question 9

ID the benefits and place in therapy for behavioral counseling for smoking cessation

Answer 9

• providing 4-7 + sessions increase cessation rates
• longer sessions (>10min) are associated w/ increased success
• the more formats you provide, the higher the quit rates (QUIT line; pamphlets not as effective)

Question 10

Contraindications for nicotine gum

Answer 10

• TMJ - vigorous chewing can exacerbate
• Dental appliances - can be damaged by gum or cause difficulties
• Poor dentition - difficulty chewing to get max effect

Question 11

When to use the 2mg dose of nicotine gum

Answer 11

• <25 cigs/day

- if you smoke your first cig more than 30 mins after waking up

Question 12

When to use the 4mg dose of nicotine gum

Answer 12

• > or equal to 25 cigs/day

- if you smoke your fist cig w/i 30 min of waking up

Question 13

What is the recommended dosing schedule for nicotine gum?

Answer 13

• 1st 6 weeks: 1 piece every 1-2 hrs
• next 3 weeks: 1 piece every 2-4 hrs
• additional 3 weeks: 1 piece every 4-8 hrs
• then dc
• max benefit from scheduled use vs. waiting for craving

Question 14

what is the daily max number of pieces of nicotine gum?

Answer 14

24

Question 15

What is the appropriate chewing technique for nicotine gum

Answer 15

• “chew and park”
• chew gum until you taste a peppery/minty flavor then park b/w gum and cheek for 30 min. to help w/ absorption
• repeat until taste is gone
• avoid food/drink 15 min. before or during treatment
• avoid acidic beverages before and during use

Question 16

Adverse effects of nicotine gum

Answer 16

• mouth soreness
• dyspepsia
• hiccups
• jaw ache
• n/v
• abdominal pain
• constipation
• excessive salivation
• mouth ulcers/irritation

Question 17

based on smoking hx, how do you select the correct dose for a nicotine lozenge?

Answer 17

same as for the gum

Question 18

recommended dosing schedule for nicotine lozenge

Answer 18

• weeks 1-6: 1 lozenge every 1-2 hrs
• weeks 7-9: 1 lozenge every 2-4 hrs
• weeks 10-12: 1 lozenge every 4-8 hrs

Question 19

adverse effects of nicotine lozenges

Answer 19

• heartburn
• hiccups
• coughing
• n/v/d
• HA
• abdominal pain

Question 20

what is the daily max number of nicotine lozenges?

Answer 20

do not use more than 5 lozenges in 6 hours or more than 20 lozenges per day

Question 21

What NRT has the most rapid onset and most closely mimics the nicotine concentrations in the brain?

Answer 21

nicotine nasal spray

Question 22

Which NRT has the highest dependence potential?

Answer 22

nicotine nasal spray

Question 23

What should you avoid before using the NRT products orally?

Answer 23

food and drink

Question 24

contraindications for the nicotine nasal spray

Answer 24

reactive airway dz (asthma)

Question 25

adverse effect associated w/ nicotine nasal spray

Answer 25

moderate to severe nasal irritation

Question 26

adverse effects associated w/ the nicotine inhaler?

Answer 26

- local mouth irritation - coughing - rhinitis

Question 27

directions with the nicotine patch

Answer 27

- worn for 24 hrs, removed and replaced each morning - apply patch as soon as you wake up - remove old patch and apply new one to hairless location b/w neck and waist

Question 28

how to manage skin irritation secondary to the nicotine patch

Answer 28

- rotate patch site | - use 1% hydocortisone cream

Question 29

how to manage insomnia secondary to the nicotine patch

Answer 29

-remove patch prior to bedtime

Question 30

dosing strategy for varenicline (Chantix)

Answer 30

- days 1-7 before quit date: 0.5mg daily X 3 days, 0.5 mg BID X 4 days - maintenance dose (starting day 8): 1 mg BID x 11 weeks

Question 31

side effects of varenicline (Chantix)

Answer 31

- CNS side effects: insomnia, abnormal dreams, HA, suicidal ideation, depression, irritability, anxiety, agitation - GI: nausea (very high occurrence), constipation, dysguesia, abdominal pain - CVS: chest pain, angina

Question 32

dosing strategy for buproprion (Zyban)

Answer 32

- begin 1-2 weeks before quit date - 150 mg PO daily x 3 days, increase to 150mg BID for 7-12 weeks - consider maintenence of 150mg BID x 6 mos - can be used w/ or w/o NRT

Question 33

side effects of buproprion (Zyban)

Answer 33

- insomnia - dry mouth - tremor - rash - HA

Question 34

how to manage insomnia secondary to buproprion (Zyban)

Answer 34

take evening dose earlier

Question 35

contraindications to buproprion (Zyban)

Answer 35

avoid in patients w/ a hx of seizures, eating disorders or use of MAOI w/i 14 days

Question 36

special populations

Answer 36

- should always receive behavioral modification - includes: - light smokers (<10 cigs/day) - pregnant/breastfeeding - psychiatric illness - CVD - adolescents - pts concerned w/ weight gain - hospitalized pts

Question 37

light smokers

Answer 37

- little evidence supporting effectiveness of therapies | - may need dosing adjustments

Question 38

pregnant/breastfeeding

Answer 38

- to be be encouraged to quit w/o pharmacotherapy - the earlier the better - use smallest effective dose but consider risk vs. benefit - safety date for NRT is variable but less nicotine is delivered to fetus than w/ cigs - buproprion may cause miscarriage and congenital anomalies in 1st trimester - no data for varenicline

Question 39

psychiatric illness

Answer 39

- higher smoking prevalence - greater tobacco related morbidity and mortality - greater risk of relapse during cessation attempts - many psych meds interact w/ smoking cessation - options: NRT; reasonable success w/ buproprion; can consider varencicline but monitor

Question 40

CVD

Answer 40

- NRT: overall safe, may consider lower dose; patch generally safe but not recommended in recent MI - buproprion: safe and effective - varenicline: small increased risk of certain CV ADRs - weigh benefit vs. risk

Question 41

Adolescent/peds

Answer 41

- behavioral modification is mainstay - patch or gum has shown to be safe - in the US a prescription is required to allow people under 18 to buy patches or gum

Question 42

pts concerned w/ wight gain

Answer 42

- no tx prevents it - lozenge, gum and buproprion may delay it - general gain is fewer than 10 pounds but can be up to 30 - be honest about it - encourage exercise and healthy diet - make referrals if needed

Question 43

hospitalized patients

Answer 43

- unique opportunity - smoke free hospital policy and possible motivation to quit d/t illness that led to hospitalization - combo counseling and transdermal patch have been used - post-hospitalization f/u is key