tobacco Flashcards
Transdermal Patch
general dosing
24 hour: Habitrol + generic (matrix)
General dosing:
● 6 wks at higher strength followed by 2 wks at intermediate and 2 wks at lowest strength
●Traditional vs titration approach
Transdermal Patch
Advantages
● Steady-state nicotine levels are achieved throughout the day (16 -24 hours)
● Easy to use and conceal
● Improved compliance
● Can be used in combination with other NRT products
● Fewer AE
Transdermal Patch
Disadvantages
●Requires 2-3 days to get maximal serum levels
●Reservoir: cannot be cut
●Local irritation to nicotine, adhesive, or allergic reactions or to the adhesive may occur
o Rx with topical steroid cream, ICS
o Rotate site
● Patient with underlying dermatologic conditions (psoriasis..) should not use
● Harder to titrate dose
Nicotine gum
general dosing
Nicotine Gum ● Nicorette, Thrive (2mg, 4mg) ● Chew & park” technique General dosing: ● 2 mg – 4 mg; 10-12 pieces per day ● < 15 cigs/day = 2 mg ● > 15 cigs/day=4 mg
Nicotine gum
advantages
● Effect within 15 minutes
● Patient controlled, easy to titrate dose
● May delay weight gain
Nicotine gum
disadvantages
● Gum chewing may not be socially acceptable
● May stick to dental work and denture
● Sore mouth
● Unpleasant taste
● Proper chewing technique (chew/park) needed to minimize adverse effects
● Cannot eat or drink 15 min before or
while using gum
Nicotine Lozenges
general dosing
● 15-25/day ● < 1 pack per day=2mg (Nicorette) = 1mg (Thrive) ● >1 pack per day = 4 mg (Nicorette)=2 mg (Thrive) Suck until strong flavor, then park ● Slowly dissolves in stomach if accidentally swallowed
Nicotine Lozenges
advantages
● Effect within in 15 min ● Max absorption 20 min ● Easy to use and conceal ● Patient can titrate to effect ● Good with dentures/dental work
Nicotine Lozenges
disadvantages
Increased AE if swallowed or chewed.
● No chewing – allow for slow dissolution. (Park/suck)
● Avoid acidic beverages and foods during 15 min pre/post
● Use beyond 6 months not recommended
Nicotine Inhaler
general dosing
● Absorbed from oral mucosa – not lungs
● Each cartridge lasts ~ 20 min of continuous puffing
● 10 puffs = 1 puff of cigarette
● 6 – 12 cartridges/day x 3-12 weeks then wean daily over 6 – 12 wk, or continue as long as necessary
Nicotine Inhaler
advantages
● Effect within 15 minutes
● Patient can titrate to effect
● Mimics the hand to mouth ritual of smoking
● Good with dentures/dental work
Nicotine Inhaler
disadvantages
● Initial throat or mouth irritation (1st week)
● Dry mouth
● cough
● Use with caution in patients with bronchospastic conditions
● Avoid acidic beverages and foods during 15 min pre/post
● Not like smoking: inhale into mouth not lungs
● Store away from light
Nicotine mouth spray
Nicorette quick mist (1 mg)
general dosing
Each spray = 1 mg nicotine
● 150 sprays/canister
General dosing
● 1-2 sprays q30-60 min. max 4 sprays/hr; 64 sprays/day
● Weeks 1-6: 1-2 sprays q30 min. Weeks 7-9: reduce by number of sprays to ½ by end of week 9. Week 10-12; stop treatment when dose reduced to 2-4 sprays per day
Nicotine mouth spray
advantages
● Rapid onset: within 60 seconds
● can titrate
● Absorbed through oral mucosa
Nicotine mouth spray
disadvantages
● Avoid acidic beverages and foods during 15 min pre/post
● Need to prime
● Some alcohol in product
● Unpleasant taste
● Irritation, pain and or tingling of throat, mouth lips
● Dry mouth
NRT AE
o Common AE with NRT: insomnia, nausea, headache
o Demonstrated safety in stable cardiovascular disease
o Possible exceptions
o Unstable angina
o Recent heart attack
o Acute heart failure
o Unstable arrhythmia
Bupropion
MOA
inhibitor of the neuronal uptake of norepinephrine, serotonin and dopamine MOA in smoking cessation unknown.
- also indicated for depression
Varenicline: ɑ4β2 nicotinic acetylcholine receptors
MOA
partial agonist: partial stimulation of receptor mediated release of dopamine in the reward center and competitive inhibitor of receptor binding by nicotine delivered by cigarettes.
Thereby suppressing nicotine withdrawal symptoms
- Nicotine antagonist effects: prevents binding of nicotine.
- caution with psychiatric history
Bupropion
(Zyban, Wellbutrin)
general dosing
Abstinence at 12 months: 18.5% vs PB 6.6%
● Begin 1-2 wks prior to quit date
● 150 mg once daily x 3 days then BID
● Recommended use: 12 wk then taper over 6 - 12 weeks
● Take with food
Bupropion
Advantages
● Oral formulation ● May benefit patients with co-existence depression ● Can be initiated before quit date ● No risk of nicotine toxicity ● May delay weight gain
Bupropion
disadvantages
Slower onset (1-2 wks) Common AE ● Dry mouth & insomnia, agitation, unease ● Titrate the dose down! Less Common AE: ● Risk of seizure is 1/1000 ● Risk factors for seizure ◦ Seizure disorders ◦ Eating disorders ● Drug interactions Contraindications: hx seizures, MAOI use
Varenicline
(Champix)
general dosing
Abstinence at 12 months 22% vs BUP 15% vs PB 9%
12 week course ● Start 1-2 week prior to quit date ● 0.5 mg once daily x 3 days, then ● 0.5 mg BID x 4 days, then ● 1 mg BID x 11 wk ● “Initial dosing pack:” 11 x 0.5 mg tabs; 14 x 1 mg tablets ● Requires dose adjustment in renal disease (max 0.5 mg BID) ● Take with food & water
Varenicline
Advantages
● Reduces nicotine craving, “pleasure” of smoking
● Diminish withdrawal symptoms
● Oral formulation
● Initiate before quit date
● New mechanism of action
● Benefit those who failed other medications
Varenicline
disadvantages
Common AE:
● Nausea (may induce nausea in up to 30%of
patients), insomnia, and abnormal/vivid dreams, taste disturbance
Less Common AE:
● Health Canada warning; Psychiatric effects (not black box)
● Need to titrate
● Post marketing surveillance warning by FDA and Health Canada
- Contraindications: endstage renal, epilepsy, suicidal, pregnancy
