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Pharmacology > smoking cessation > Flashcards

smoking cessation Flashcards

1
Q

smoking and nicotine

A

-Other toxins in tobacco smoke, not nicotine, are responsible for majority of adverse health effects
-> 4000 different chemicals
-tar, carbon monoxide, irritant and oxidant gases
-> 40 carcinogens

-The main adverse effect of nicotine from tobacco is addiction, which sustains tobacco use
-Nicotine dependence leads to continued exposure to toxins in tobacco smoke

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2
Q

smoking statistics

A

-Tobacco
-#1 cause of disease and premature death
-Leading preventable cause of mortality

-480K deaths/year
-11.5% of adult Americans smoke (28.3M)
-13.1% Men, 10.1% Women

-~2K young people <18yo start each day
-Cost - $100 billion/yr
-68% - have desire to quit
-55% - try to quit annually
-7.5% - who try to quit succeed

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3
Q

smoking and cardiovascular disease

A

-Smoking increase risk of CVD
-Smoking cessation significantly decrease risk within 1–3 years
-Smoking-related factors contributing to CV risk include:
-increased thrombogenesis
-carbon monoxide
-oxidative damage
-hyperlipidemia

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4
Q

properties of nicotine

A

-Has stimulant and depressant effects
-Rapidly absorbed from mouth and respiratory tract into blood stream.
-Can bind to and stimulate nicotinic receptors in autonomic ganglia, CVS, respiratory system and nervous system

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5
Q

pharmacological actions of nicotine: Cardiovascular system

A

-positive inotropic, positive chronotropic
-increase cardiac output
-increase SBP & DBP

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6
Q

pharmacological actions of nicotine: respiratory system

A

-Low dose - increase respiration via activation of chemoreceptors in aortic arch and carotid bodies
-High dose - increase respiration by direct stimulation of respiratory center
-Toxic doses – respiration depressed by inhibiting the respiratory centers in brainstem and complex action at receptors of neuromuscular junction

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7
Q

pharmacological actions of nicotine: CNS

A

-Mild euphoria, increase arousal and concentration, improved memory, appetite suppression
-Tremors, convulsions, respiratory stimulation
-Nausea and vomiting (tolerance dvps quickly)

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8
Q

pharmacokinetics of nicotine

A

-Well absorbed from mucous membranes
-Widely distributed, crosses BBB and placenta
-Inhibits monoamine oxidase – may have dopamine like effects
-Nicotine metabolism is induced by the tars in cigarette smoke (via CYP450) – leads to pharmacokinetic tolerance
-Nicotine also can induce metabolism of beta-blockers, BDZ, opiods and theophylline
-pregnant- mom smokes -> baby smokes (kicking, tachycardia)

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9
Q

smoking cessation

A

-Aversion Therapy
-Patient associates smoking with something undesirable
-Not very effective
-Often used w/ hypnosis or acupuncture

-Substitution Therapy - NRT
-Abrupt Withdrawal – “cold turkey” May be combined w/ agents to reduce craving

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10
Q

tobacco cessation guidelines

A

-Department of Health & Human Services
-3 types of patients:
-Those willing to quit
-Those unwilling to quit
-Past users who recently quit

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11
Q

pts willing to quit

A

-5 steps to intervening and motivations
-5As
-ASK- systematically identify all users at every visit
-ADVISE- strongly urge all users to quit
-ASSESS- determine if pt is willing to quit or not
-ASSIST- help pt set up a plan to quit
-ARRANGE- schedule follow up contacts to reinforce quitting and identify problem with current plan, best to do during 1st week, 1st month, then PRN

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12
Q

pts NOT willing to quit

A

-5 steps to intervening and motivating
-5Rs
-RELEVANCE- help pt determine specific areas in life that would benefit from quitting
-RISKS- help pt identify neg consequences of smoking
-REWAREDS- help pt identify benefits to quitting
-ROADBLOCKS- help pt identify barriers to quitting
-REPETITION- encourage pt to quit at every visit

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13
Q

pts who recently quit

A

-Reinforce their decision
-Review the benefits of quitting
-Help with problems that may be encountered by quitting

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14
Q

nicotine replacement therapy

A

-Nicotine replacement therapy (NRT) can be used instead of tobacco to aid quitting
-NRT delivers nicotine without the toxins from tobacco
-NRT helps combat the symptoms of withdrawal
-Nicotine dose from NRT is lower and administered more gradually than with smoking and this reduces the addictive potential

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15
Q

plasma nicotine concentrations for smoking and NRT

A

-nasal is fastest but irritates

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16
Q

smoking and cardiovascular disease

A

-NRT can be used safely by majority of people with cardiovascular disease, even with concomitant smoking
-Meta-analysis shows no difference in rate of acute MI between NRT patch and placebo
-The benefits of NRT outweigh the risks, even in smokers with cardiovascular disease

17
Q

nicotine replacement therapy

A

-All considered First line agents
-Nicotine gum
-Nicotine inhaler
-Nicotine nasal spray
-Nicotine patch
-Nicotine lozenge

18
Q

nicotine gum

A

-nicorette
-Dosing
-If < 24 cigarettes/day – 2 mg gum up to 24 pieces per day
-If > 24 cigarettes/day – 4 mg gum up to 24 pieces per day

-Duration- 12 weeks
-ADRs – dyspepsia, mouth soreness
-Instructions – Chew slowly to avoid jaw ache and increase buccal absorption
-chew 1-2 times and hold in cheek for most efficacy

19
Q

nicotine inhaler

A

-nicotrol
-Dosing: 6 – 16 cartridges/day
-Duration: 6 months
-ADRs: Local irritation of mouth and throat
-Instructions: Best effect with frequent continuous puffing (20 minutes)
-oral fixation

20
Q

nicotine nasal spray

A

-nicotrol NS
-Dosing: Each dose (2 sprays=1mg nicotine) 1-2 sprays/hr; max is 5 doses (10 sprays) per hour and 40 doses/day
-Duration; 3-6 months
-ADRs: nasal irritation

21
Q

nicotine patch

A

-Nicoderm CQ, Habitrol, Nicotrol, ProStep
-Dosing: Most common regimen
-21mg/24 hr x 4 weeks
-14mg/24 hr x 2 weeks
-7mg/24 hr x 2 weeks
-(Nicotrol comes in 15mg,10mg & 5mg/24 hr)

-ADRs – local skin reaction, insomnia

22
Q

nicotine lozenge

A

-commit
-Dosing:
-If 1st cigarette smoked 30 min after waking up, use 2mg lozenge
-If 1st cigarette smoked within 30 min of waking up, use 4 mg lozenge
-Use 1 lozenge q1-2 hrs x 6wks then
-Use 1 lozenge q2-4 hrs x 3 wks then
-Use 1 lozenge q4-8 hrs x 3 wks

-ADRs – sore throat

23
Q

safety of NRT

A

-Risk of cancer from NRT is negligible compared to the risk from continued smoking
-Nicotine per se is not a known cause of cancer
-Other tobacco smoke constituents are believed to be responsible for cancers
-Studies carried out in rodents demonstrate that under normal conditions nicotine is not carcinogenic

24
Q

NRT and pregnancy

A

-Maternal smoking is associated with poor pregnancy and childhood outcomes
-Many toxins in tobacco smoke could be responsible
-Nicotine is a potential fetal teratogen
-Nicotine may contribute to obstetrical complications in pregnant women and to sudden infant death syndrome
-Benefits of NRT outweigh the risks of smoking during pregnancy

25
Q

abuse liability of NRT

A

-Prevalence of abuse and dependence with current NRT products is almost zero (patch) or very low (<10% gum, nasal spray, inhaler)
-Likely to be greatest with products that deliver nicotine rapidly, but less than that of cigarettes
-Even if dependence develops, there is likely to be overall health benefit if individual no longer smokes

26
Q

Bupropion SR

A

-First line agents
-MOA: Antidepressant – Weak inhibitor of neuronal uptake of serotonin, NE and dopamine. Does not inhibit MAO.
-Precautions: Seizure risk. (Higher risk w/ doses > 450mg per day or individual dose > 150mg)
-ADRs – insomnia, dry mouth, HTN ( risk w/ nicotine patch)
-Dose: Start 2 weeks before quit date. 150 mg PO qam x 3days then 150mg PO bid for 7-12 weeks. May use for up to 6 months

27
Q

varenicline

A

-first line agent
-MOA – Partial nicotinic ACH receptor agonist. Reduces craving and withdrawal symptoms
-Precautions – Nausea. Take w/ full glass of water to decrease nausea symptoms
-Common ADRs – GI effects, (nausea, vomiting, dysgeusia) sleep disturbances, headaches, abnormal dreams, anxiety, irritability.

28
Q

chantix adverse effects

A

-first line
-Behavioral & Psychiatric side effects: anxiety, depression, emotional disturbances, irritability, restlessness, vivid dreams, angry outbursts, irrational behavior, suicidal ideation
-Report from ISMP:
-Accidents/injuries
-Visual disturbances
-Dysrhythmias
-Seizures
-Dermatological reactions
-Diabetes

29
Q

chantix dosing

A

-Dosing: Start one week before quit date and continue for 12 weeks. If patient successfully quits – then may continue treatment for additional 12 weeks to maintain success
-Titrate dose as follow:
-Day 1-3: 0.5 mg PO QD
-Day 4-: 0.5 mg PO BID
-Day 8 – end of treatment: 1 mg PO BID

30
Q

chantix efficacy

A

-FDA-approval based on combined data from 5 clinical trials (3659 patients total)
-Smoked at least 10 cigarettes per day (Average 21 cigarettes per day for an average of 25 years)
-Compared to placebo: More effective in reducing urge to smoke, less withdrawal and more likely to maintain abstinence during follow-up
-Compared to bupropion: Similar efficacy rates with less adverse effects and precautions

31
Q

2nd line

A

-not FDA approved for smoking cessation
-Reduce the craving. MOA unknown

-Nortriptyline (Pamelor) (antidepressant)
-Dose: 75mg-100mg/day for up to 12 weeks
-ADRs – risk of arrhythmia, sedation, dry mouth

32
Q

3rd line

A

-limited efficacy
-Clonidine (Catapres) (alpha2 agonist)
-Dose: 0.15-0.75 mg/day for 3-10 weeks
-Can use PO or patch
-ADRs – rebound HTN, dry mouth, CNS effects

33
Q

investigational tx: nicotine vaccine

A

-MOA: Induce antibodies which bind to nicotine → Nicotine cant cross blood brain barrier → Reduces reinforcing action of nicotine in the brain
-Efficacy: Phase 2 trial. Showed improved abstinence rates in vaccine group at two months (47% vs. 35%), but differences in continued abstinence at 6 months was not statistically significant. Subgroup analysis did show that vaccine patients with higher antibody levels did have higher abstinence rates between 2-6 months.
-Further research with immunotherapy needed

34
Q

counseling and behavioral therapy

A

-Should be utilized in combination w/ pharmacological therapy
-Includes:
-practical counseling (problem solving and skills training)
-social support
-person to person contact

35
Q

other pharm tx

A

-appetite suppressants
-benzodiazepines
-beta-blockers
-buspirone
-caffeine/ephedrine
-cimetidine
-dextrose tablets (food supplement)
-lobeline
–moclobemide (monoamine oxidase inhibitor)
-SSRIs

36
Q

US public health service guidelines

A

-Clinic screening systems such as expanding the vital signs to include tobacco use status, or the use of other reminder systems such as chart stickers or computer prompts are essential for the consistent assessment, documentation and intervention with tobacco use
-All patients should be screened for tobacco use and assessed for their interest in quitting.
-All physicians and clinicians should strongly advise every patient who smokes to quit
-All healthcare personnel and clinicians should repeatedly and consistently deliver smoking cessation interventions to their patients.
-Patients should be encouraged to use nicotine replacement therapy or bupropion/varenicline for smoking cessation
-To be most effective, interventions should include either individual, group or telephone counselling/contact

37
Q

areas for further research

A

-The elements of behavioural interventions that enhance effectiveness
-Effectiveness of combining:
-different NRT formulations
-NRT and non-nicotine pharmacotherapies

-Long-term use of NRT or other pharmacotherapies to prevent relapse or reduce harm
-Interventions for adolescent smokers
-Improving access to effective interventions
-Organization of healthcare systems for delivery of appropriate interventions
-Optimal sequence of treatment combinations for repeated attempts to quit
-Treatment of smokers with co-morbidities

38
Q

summary

A

-Toxins in tobacco smoke cause most adverse health effects
-Nicotine is addicting therefore it sustains tobacco use
-Smoking Cessation Therapy may include aversion therapy, substitution therapy or abrupt withdrawal
-Tobacco Cessation Guidelines have identified 3 types of patients for smoking cessation
-Nicotine Replacement Therapy is first-line per guidelines. It is available in various dosage forms and essentially helps reduce the withdrawal symptoms associated with quitting
-NRT can be combined with bupropion (also first-line) to reduce craving
-Varenicline (Chantix) is a partial nicotinic receptor agonist used to reduce craving and withdrawal. It is considered first-line but not yet part of official guidelines. Chantix is associated with potential behavioral and psychiatric side effects
-The success rate for quitting is increased when pharmacological agents are combined with counseling and behavioral therapies

Pharmacology (16 decks)

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