smoking cessation (NAPLEX)

5 A's

Ask about tobacco use

Advise to quit

Assess readiness to quit

Assist with quit attempt

Arrange follow up

What patients have exceptions to drug TX? (3) **

Pregnant

Adolescents

Light smokers (<10 cig/day)

What CYP does smoking target?

CYP450 1A2 inducers

Smoking DDI with patients who quit (2)

Increase theophylline dose

Increase warfarin dose

What medication should be avoided in female smokers?

Estrogen containing OC in patients >35 years old due to increased risk of CV disease

Vaccinations in smokers aged 19-49 (2)

Pneumococcal

Influenza

Preferred TX for smoking cessation ** (2)

Combination NRT with LA patch and SA gum/lozenge

Varenicline monotherapy

NRT examples (4)

Patch (NicoDerm CQ)

Gum (Nicorette)

Lozenge (Nicorette Mini)

Nasal spray RX

How many cigarettes in a pack haha

20

Pack per year equation

(# cig packs per day) x (# of years smoked)

NICOTINE PATCH DOSING

>10 cig/day:

21 mg/day x6 weeks

14 mg/day x2 weeks

7 mg/day x2 weeks

<10 cig/day:

14 mg/day x6 weeks

7 mg/day x2 weeks

GUM/LOZ DOSING

<30 min after waking:

4mg q1-2hr x6 weeks

4mg q2-4hr x3 weeks

4mg q4-8hr x3 weeks

>30 min after waking:

2mg q1-2hr x6 weeks

2mg q2-4hr x3 weeks

2mg q4-8hr x3 weeks

What patients should NRT be avoided in? (2)

CV: post-MI, arrhythmias, angina

Pregnancy

What medication should be avoided in COPD/Asthma?

Nasal spray

Main NRT adverse effect (1)

Insomnia

Main adverse effects with patch? (2)

Vivid dreams

Skin irritation

The FDA prohibits sale of nicotine products to patients < ____ years and identification is required to purchase.

<21 years old

Should the nicotine patch be removed prior to MRI?

YES

Can you eat/drink when using loz/gym?

NO - do not eat/drink 15 minutes before or during use

Gum & loz (sugar free): ___ mg strength can reduce or delay weight gain

4 mg

Buproprion MOA

Blocks neuronal reuptake of dopamine and norepinephrine

BUPROPION SR dosing **

start, SR dosing, spacing, max dose

Start 1-2 weeks before quit date to allow time to reach steady state

SR: 150mg QAM for 3 days, then increase to 150mg BID

Take first dose in the morning then take second dose at least 8 hours after first dose

Max dose: 300mg/day

Bupropion BW

Increased risk of suicidal thinking and behavior in children, adolescents, and young adults taking antidepressants

Bupropion Contraindications (5)

Seizures

Anorexia/bulimia

MAOI

Linezolid

Methylene blue

Bupropion adverse effects (5)

dry mouth

insomnia

serious neuropysch events

tremors

weight loss

Varenicline MOA

Partial neuronal alpha-4/beta-2 nicotinic receptor agonist

Start 1 week before quit date

A. Bupropion

B. Varenicline

B. Varenicline

Start 1-2 weeks before quit date

A. Bupropion

B. Varenicline

A. Bupropion

Varenicline adverse effects (6)

headache

insomnia

nausea

seizures

serious neuropsyc events

vivid dreams

PATCH COUNSELING

Press patch on clean skin for ~10 sec

Wear for 24 hours

If vivid dreams occur, remove the patch prior to bedtime and apply a new one in the AM

Fold sticky ends together and put in trash can with lid

Wash hands before and after

Rotate patch site

NEVER cut patch

Never wear more than 1 patch at a time

Nicotine GUM counseling

chew slowly until gum starts to tingle or become peppery

park between the cheek and gum

when tingle stops, pull out and chew until tingle returns then park again

repeat until flavor is gone (~30 min)

dont eat/drink 15 min before or during use

Nasal spray counseling

Tilt head back slightly

Spray once in each nostril while breathing through the mouth

Do not sniff, swallow, or inhale through the

Can cause sneezy, coughing, watery eyes, runny nose, and a hot peppery feeling in the back of the throat