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What are some benefits of smoking cessation?
lowers the risk of lung and other types of cancer
reduces the risk of heart disease and stroke w/in 1 to 2 years by 50%
after 5 to 10 years, a previous smoker's risk for heart disease is equal to someone who never smoked
reduces respiratory symptoms
slows the rate of decline in lung function
reduces the risk of infertility
What are the two sides of the problem of tobacco dependence?
Physiological and behavioral
What describes physiological tobacco dependence?
the addiction to nicotine
What describes behavioral tobacco dependence?
The habit of using tobacco
What is true of treatments for tobacco dependence?
They should address the physiological and behavioral aspects of dependence
What should we start with in the treatment of tobacco dependence?
A good medical history; helps tailor therapy, avoid risky therapies, find out about the support they may or may not have, and gives insight into their motivation to quit
What kind of questions should we ask a patient who is not ready to quit smoking?
Do you ever plan to quit?
How would it benefit you to quit now, instead of later?
What would have to change for you to decide to quit sooner?
What are the 5 A's of counseling?
Ask- ask if they smoke cigs
Advise - offer personalized advice to quit
Assess - Ask if the patient is willing to quit
Assist - Behavioral counseling + FDA Rx
Arrange - Arranging a follow-up visit
What are some behavioral counseling points we can provide patients dealing with tobacco dependence?
set a quit date
tell others and ask for support
plan for challenges/cravings
remove all tobacco products
clean house, car, clothing
emphasize abstinence
use a calendar and contact
brainstorm better uses of money
quit lines
What are the 7 FDA approved medications for tobacco cessation?
nicotine gum,
nicotine patch,
nicotine lozenge,
nicotine nasal spray,
nicotine inhaler,
bupropion SR (Zyban),
varenicline (Chantix)
What are some typical challenges that come with tobacco cessation?
Craving and withdrawal symptoms, facing triggers, and fear of weight gain
What is the MOA of bupropion SR?
Blocks neuronal reuptake of dopamine and norepinephrine
What is the MOA of varenicline?
Partial nicotinic receptor agonist
When should bupropion SR and varenicline be started and how long should treatment last when treating tobacco dependence?
Start 1 week before the quit date and continue for 3 months in total
What are some exclusions for self treatment of tobacco cessation?
severe heart disease (MI, arrhythmia, severe angina)
high blood pressure not controlled with medication,
pregnancy or breastfeeding,
under 18 years old,
active peptic ulcer disease
What is not FDA approved for smoking cessation?
E-cigarettes
What is true of e-cigarettes?
There is no long-term safety data; other methods should be reinforced to help quit smoking
What FDA-approved medications for smoking cessation are classified as NRTs? (nicotine replacement therapies)
nicotine gum, lozenge, patch, nasal spray, oral inhaler
What are some first-line pharmacotherapies for smoking cessation not classified as NRTs?
Bupropion SR and varenicline
Why do we want to give NRTs or other medications for smoking cessation?
They reduce physical withdrawal from nicotine,
eliminate the rewarding effects of nicotine,
allow the patient to focus on behavioral/psychological aspects of tobacco cessation
How long can nicotine withdrawal symptoms last?
From 12 weeks to up to 6 months
What is the proper chewing technique for nicotine?
Chew slowly → stop chewing at the first sign of peppery taste or tingling sensation → park between cheek and gum, → chew again when the peppery taste or tingle fades
How should nicotine gum/lozenges be dosed?
If first cig. of day is more than 30 mins after waking up: 2 mg gum/lozenge
If first cig. of day is within 30 mins after waking up: 4 mg gum/lozenge
What is the recommended duration of treatment with nicotine gum/lozenges?
12 weeks
What is the appropriate starting dose of the nicotine patch for someone who smokes 10 cigarettes a day or less?
14 mg * 6 weeks → 7 mg * 2 weeks
What is the appropriate starting dose of the nicotine patch for someone who smokes more than 10 cigarettes a day?
21 mg * 6 weeks → 14 mg * 2 weeks → 7 mg * 2 weeks
Which NRTs are available only by prescription?
Nicotine nasal spray and oral inhaler
What is the max amount of nicotine gum per day?
24 pieces
What is the max amount of nicotine lozenges per day?
20 pieces
What is the recommended duration of treatment with nicotine transdermal patches?
8 - 10 weeks
6 → 2 → 2 weeks or
6 → 2 weeks
What is important to remember about nicotine transdermal patches?
The patch application site should be rotated daily
How should nicotine nasal spray be dosed?
1 - 2 doses per hour
spray into each nostril
What is the max amount of nicotine nasal spray per day?
40 doses
How should nicotine oral inhalers be dosed?
6 - 16 cartridges per day
What is the recommended duration of treatment with nicotine nasal spray?
12 weeks
What is the recommended duration of treatment with a nicotine oral inhaler?
3 - 6 months
What is the max dose of bupropion SR?
300 mg/day
Which smoking cessation medication is contraindicated in patients with a history of seizures?
bupropion
What kind of adverse effects can you expect with the use of nicotine gum/lozenges?
mouth irritation, hiccups, GI complaints
What kind of adverse effects can you expect with the use of nicotine transdermal patches?
local skin reactions and sleep disturbances
What kind of adverse effects can you expect with the use of nicotine nasal spray?
nasal/throat irritation, ocular irritation, sneezing, cough
What kind of adverse effects can you expect with the use of nicotine oral inhalers?
Mouth/throat irritation, cough, hiccups, GI complaints
What are some precautions to keep in mind when recommending NRTs?
Recent heart attack (2 weeks),
heart arrhythmias,
angina,
pregnancy/breastfeeding,
being under 18 years old
What are some precautions to keep in mind when recommending bupropion SR (Zyban)?
medications that lower the seizure threshold,
hepatic impairment,
pregnancy/breastfeeding,
being under 18 years old
What are some contraindications for Bupropion SR (Zyban)?
Seizure disorders,
concomitant bupropion (Wellbutrin) therapy,
bulimia/anorexia nervosa,
abrupt discontinuation of alcohol/benzos,
use of MAOIs (w/in 2 weeks)
What are some precautions to keep in mind when recommending varenicline?
Renal impairment,'
pregnancy/breastfeeding,
being under 18 years old,
can cause severe neuropsychiatric symptoms
How many medications are FDA-approved for smoking cessation?
7
bupropion, varenicline, & 5 NRT
How many NON-PRESCRIPTION medications are FDA-approved for smoking cessation?
Three Gum, lozenges, patch
What are some causes of reflux disease?
Esophageal dysmotility,
the ineffective barrier between the esophagus and stomach,
stomach abnormalities
What are some typical symptoms of reflux disease?
heartburn and regurgitation
How can reflux disease be identified?
If a patient takes acid medication and it relieves their typical reflux symptoms, the symptoms were probably due to acid reflux
How can reflux disease be diagnosed?
Endoscopy; can see erosive esophagitis or Barrett's esophagus
What are some non-pharmacologic treatments for heartburn and dyspepsia?
Weight loss,
head of bed elevation,
avoiding meals 2-3 hours before bedtime,
avoiding trigger foods
What are the different types of pharmacologic treatments for heartburn and dyspepsia?
Antacids/bismuth-containing products,
histamine type 2 receptor antagonists,
proton pump inhibitors
What is the MOA of antacids?
neutralize stomach acid to form water
What kind of effect would a magnesium-containing antacid have?
laxative effects
Renally-eliminated
What kind of effect would an aluminum-containing antacid have?
causes constipation
avoid in renal failure
What are some precautions with the use of magnesium-containing antacids?
diarrhea and renal impairment
What are some precautions with the use of aluminum-containing antacids?
Constipation, and overuse can lead to hypophosphatemia, and should be avoided in renal failure
What are some precautions with the use of calcium-containing antacids?
Belching,
flatulence,
constipation,
kidney stones,
should be avoided in renally impaired patients
What are some precautions with the use of sodium bicarbonate?
belching,
flatulence,
fluid overload,
systemic alkalosis,
milk-alkali syndrome
How can most drug interactions with antacids be avoided?
Separating doses by 2 to 4 hours
Antacids + antifungals, iron, atazanavir
Antacids + rosuvastatin
Antacids + enteric coated meds
Separate by 2+ hrs
Antacids + Levothyroxine
Separate by 4 hrs
Antacids + Amphetamines
AVOID CONCURRENT USE
Who should Bismuth subsalicylate not be used in?
Children - Reye’s syndrone
Those with salicylate/aspirin allergies,
anyone at risk for bleeding
What is the MOA of H2RAs?
Blocks the action of histamine on the parietal cells at histamine 2 receptors in the stomach, causing a decrease in acid secretion
How should H2RAs be used?
30 to 60 minutes before eating or at symptom onset; should not be used more than 2 times a day
What are some serious adverse effects of the use of H2RAs?
thrombocytopenia
Weak antiandrogenic effect (High dose)
Decreased libido, incompetence, gynecomastia in men
What is the MOA of PPIs?
Inhibit hydrogen potassium ATPase (proton pump) that are actively secreting acid
How should PPIs be used?
30 to 60 minutes before a meal (best before breakfast) and self care should be limited to 14 days every 4 months
What is important to remember about PPI tablets and capsules?
They should not be chewed or crushed
What are some serious adverse/choronic use effects of the use of PPIs?
Acute interstitial nephritis,
subacute cutaneous lupus erythematosus,
traveler's diarrhea,
spontaneous bacterial peritonitis
c. diff
Hypomagnesemia
What are some exclusions for self-treatment of heartburn and dyspepsia?
Antacids: Children under 2 years
H2RAs: under 12 years
PPIs: under 18 years,
heartburn that continues after 2 weeks of treatment,
unexplained weight loss
When would an H2RA be indicated over a PPI?
For infrequent, mild to moderate heartburn or dyspepsia
When would a PPI be indicated over and H2RA?
For treatment of frequent heartburn (more than 2 days a week)
PPIs + warfarin, theophylline, tacrolimus, mycophenolate
PPI inhibit CYP2C19
AVOID CONCURRENT USE
PPIs + Digoxin
PPI may increase digoxin absorption
CHECK W/ PROSCRIBER
PPIs + Methorexate
Risk of toxicity
AVOID CONCURRENT USE W/ HIGH DOSE METHO
Omeprazole, esomeprazole + clopidogrel
CYP enzyme interactions
AVOID CONCURRENT USE
Omeprazole, esomeprazole + Diazepam
Inhibit metabolism → increase concentration of target drug
AVOID CONCURRENT USE
PPI’s Generic - Brand
Omeprazole - Prilosec
Pantoprazole - Protonix
Esomeprazole - Nexium
Lansoprazole - Prevacid
Famotidine - Pepcid
Ranitidine - Zantac
What are the most frequent clinical manifestations of intestinal gas?
eructation, bloating, and flatulence
What is intestinal gas primarily composed of?
Nitrogen, oxygen, carbon dioxide, hydrogen, and methane