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Smoking Cessation: A Practical Overview of Pharmacotherapy

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Smoking Cessation: A Practical Overview of Pharmacotherapy Joseph Saseen, Pharm.D., FCCP, BCPS Professor University of Colorado Joseph.Saseen_at_ucdenver.edu – PowerPoint PPT presentation

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Title: Smoking Cessation: A Practical Overview of Pharmacotherapy


1
Smoking CessationA Practical Overview of
Pharmacotherapy
  • Joseph Saseen, Pharm.D., FCCP, BCPS
  • Professor
  • University of Colorado
  • Joseph.Saseen_at_ucdenver.edu

2
Learning Outcomes
  • Apply recommendations from guidelines to
    customize clinical interventions to patients who
    use tobacco
  • Compare and contrast advantages and disadvantages
    of various tobacco cessation pharmacotherapy
    products to

3
U.S. Department of Health and Human Services
Public Health Service (May 2008)
  • Clinical Practice GuidelineTreating Tobacco Use
    and Dependence 2008 Update

http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
4
Potential Health Benefits of Smoking Cessation
Time After Smoking
15 yrs Risk of MI and stroke reduce to level of
nonsmoker
20 min BP, HR, peripheral circulation improve
10 yrs Risk of lung cancer reduced 50
24 hrs CO levels drop
48 hrs Nicotine eliminated taste and smell
improve
1 yr Risk of MI reduced 50
3-9 mo SOB and coughing decrease
2-12 wks Lung function can improve 30
5
Nicotine Stimulates Dopamine Release
  • High nicotine levels achived in 11 seconds from
    inhalation

Nicotine and Tobacco Research 19991s121-s125
6
10 Key Guideline Recommendations
  • Repeated intervention and multiple attempts
  • Identify and document tobacco use status and
    treat every tobacco user
  • Treatments are effective counseling and
    medications
  • Brief treatment is effective
  • Counseling is important practical and social
    support

http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
7
10 Key Guideline Recommendations
  • Medications should be used whenever possible
  • Combination of counseling and medication more
    effective than either alone
  • Telephone quitline counseling is effective
  • Use motivational treatment if patients unwilling
    to quit
  • Insurance plans should include counseling and
    medication coverage

http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
8
The 5 As Model
http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
9
Meta Analysis 2008 (n18 studies)
http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
10
First Line Medications
  • Nicotine Replacement
  • Oral Agents
  • Nicotine gum
  • Nicotine inhaler
  • Nicotine lozenge
  • Nicotine nasal spray
  • Nicotine patch
  • Bupropion SR
  • Varenicline

http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
11
Nicotine Gum
  • Advantages
  • Disadvantages
  • May satisfy oral cravings
  • May delay weight gain
  • Patients can titrate therapy to manage withdrawal
    symptoms
  • Gum chewing may not be socially acceptable
  • May stick to dental work and dentures
  • Proper chewing technique (Chew/Park) needed to
    minimize adverse effects
  • Cannot eat or drink 15 minutes before or while
    using the nicotine gum

12
Nicotine Inhaler
  • Advantages
  • Disadvantages
  • Patients can easily titrate therapy to manage
    withdrawal symptoms
  • Mimics the hand-to-mouth ritual of smoking
  • Initial throat or mouth irritation (in first
    week)
  • Cartridges should not be stored in conditions
    gt86oF or lt59oF
  • Patients with underlying bronchospastic
    conditions should use with caution

13
Nicotine Lozenge
  • Advantages
  • Disadvantages
  • May satisfy oral cravings
  • Easy to use and conceal
  • Patients can titrate therapy to manage withdrawal
    symptoms
  • Gastrointestinal side effects (nausea, hiccups,
    heartburn) may be bothersome
  • Must allow slow dissolution for 20-30 minutes (no
    chewing)
  • Should not eat or drink for 15 minutes before or
    while using the nicotine lozenge

14
Nicotine Nasal Spray
  • Advantages
  • Disadvantages
  • Dose can be easily titrated to rapidly manage
    withdrawal symptoms
  • Initial nasal or throat irritation can be
    bothersome (may last up to 3 weeks)
  • Higher dependence potential relative to other NRT
    formulations
  • Patients with chronic nasal disorders (e.g.,
    rhinitis, polyps, sinusitis) or severe reactive
    airway disease should not use

15
Nicotine Patch
  • Advantages
  • Disadvantages
  • Steady-state nicotine levels are achieved
    throughout the day
  • Easy to use and conceal
  • Fewer compliance issues are associated with the
    patch
  • Patients cannot titrate dose
  • Allergic reactions to the adhesive may occur
  • Patients with underlying dermatologic conditions
    (e.g., psoriasis, eczema, atopic dermatitis)
    should not use the patch

16
Bupropion SR (Zyban)
  • Advantages
  • Disadvantages
  • Oral formulation given BID that is easy to use
  • May be beneficial for patients with coexisting
    depression
  • Initiated before quit date
  • No risk of nicotine toxicity if patient continues
    to smoke
  • Increases seizure risk
  • Several contraindications and precautions that
    may preclude use
  • Side effects of insomnia and dry mouth

17
Varenicline (Chantix)
  • Advantages
  • Disadvantages
  • Oral formulation given BID that is easy to use
  • Initiate before quit date
  • New mechanism of action for persons who
    previously failed using other medications
  • May induce nausea in up 1/3 of patients (need to
    titrate)
  • Post-marketing surveillance data stimulated FDA
    warning

18
Varenicline (Chantix)Package Insert Update
  • WARNINGS and PRECAUTIONS
  • Serious neuropsychiatric symptoms have occurred
    in patients being treated with CHANTIX. Some
    cases may have been complicated by the symptoms
    of nicotine withdrawal in patients who stopped
    smoking however, some of these symptoms have
    occurred in patients who continued to smoke. All
    patients being treated with CHANTIX should be
    observed for neuropsychiatric symptoms including
    changes in behavior, agitation, depressed mood,
    suicidal ideation and suicidal behavior.

19
Varenicline (Chantix)FDA Alert February 1, 2008
  • Recommendations and Considerations for Healthcare
    Professionals
  • Monitor all patients taking Chantix for serious
    neuropsychiatric symptoms
  • Serious psychiatric illness (e.g., schizophrenia,
    bipolar, major depressive disorder) may worsen
  • Consider these safety concerns and alert patients
    about these risks

http//www.fda.gov/Drugs/DrugSafety/PostmarketDrug
SafetyInformationforPatientsandProviders/ucm106540
.htm
20
Varenicline (Chantix)FDA Alert February 1, 2008
  • Information for the patient
  • Report any history of psychiatric illness prior
    to starting Chantix
  • Be alert to changes in mood and behavior
  • Immediately report changes in mood and behavior
  • Vivid, unusual, or strange dreams may occur
  • Medication Guide (5/16/08)
  • http//www.fda.gov/downloads/Drugs/DrugSafety/UCM0
    88569.pdf

http//www.fda.gov/Drugs/DrugSafety/PostmarketDrug
SafetyInformationforPatientsandProviders/ucm106540
.htm
21
Monotherapy
http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
22
Combination Pharmacotherapy
  • These combinations are considered effective
    according to guidelines

http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
23
Cost of Pharmacotherapy
http//www.drugstore.com
24
Bottom Line Pharmacotherapy for Smoking Cessation
  • All smokers trying to quit should be offered
    medication. except when contraindicated or for
    specific populations for which there is
    insufficient evidence of effectiveness
  • Pregnant women
  • Smokeless tobacco users
  • Light smokers
  • Adolescents

http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
25
Plethora of Resources
  • CO Quitline (www.coquitline.org)
  • Fixnixer (www.fixnixer.com)
  • Become an Ex (www.becomeanex.com)
  • My Last Dip (www.mylastdip.com)
  • Cigarette is Dead (www.thecigaretteisdeadtimeline.
    com)
  • Quit Doing it Labs (www.quitdoingitlabs.com)
  • Raise Smoke Free Kids (www.raisesmokefreekids.com)

26
Quit Tips
  • Make a quit plan. Pick a date and make a list of
    reasons you want to quit.
  • Prepare for your quit date. This means getting
    rid of all tobacco-related items, such as
    ashtrays, lighters and matches.
  • Ask your family and friends to support you in
    your quit attempt. Tell them your quit date and
    ask them to be supportive and understanding.
  • Keep a picture of your loved ones. Tape a message
    to the picture that reminds you that you are
    quitting for them. Look at the picture and read
    the message anytime you have an urge to smoke.
  • When you feel an urge to reach for a cigarette,
    try taking a walk, playing with your kids or
    running up and down the stairs instead of
    lighting up.
  • For the first few days after you quit smoking,
    spend as much free time as possible in public
    places where smoking is not allowed.
  • Reward yourself when you reach milestones in your
    quit attempt, such as buying yourself a new book
    or treating yourself to a nice dinner with a
    supportive friend.
  • Keep healthy snacks, gum, mints and toothpicks
    around, and drink plenty of water.
  • Try to avoid people, places or other trigger
    habits you typically associate with smoking.
  • Take deep, slow breaths and imagine your lungs
    filling with clean, fresh air.
  • Create a smoke-free rule for your home and car.
    Smoke-free environments can support you in the
    quitting process.
  • Dont give up. Most people have to try several
    times to quit smoking. You can do it.

www.myquitpath.com
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