FAFP2 Pharmaceutical care II Seminar: Pharmacist's role in quitting smoking 11. 3. 2020 PharmDr. Bc. Dana Mazánková, Ph.D. mazankovad@vfu.cz Learning outcomes of today • Pharmacist interventions ▫ 3A: ask, advice assist • Withdrawal symptoms • Signs of addiction • Varenicline • Bupropion • Nicotine Replacement Theraphy (NRT) Pharmacist interventions 3A: ASK, ADVISE, ASSIST 3 A’s Action Strategies for implementation Pharmacist interventions 3A: ASK, ADVISE, ASSIST 3 A’s Action Strategies for implementation Pharmacist interventions 3A: ASK, ADVISE, ASSIST 3 A’s Action Strategies for implementation Withdrawal symptoms The psychological symptoms of nicotine withdrawal include: • a strong desire or craving for nicotine • irritability or frustration • low mood • difficulty concentrating • anxiety • mood swings Withdrawal symptoms The physical symptoms of nicotine withdrawal include: • headaches • sweating • restlessness • tremors • difficulty sleeping • waking at night • increased appetite • abdominal cramps • digestive issues, including constipation • difficulty concentrating • cannot stop smoking or chewing, despite attempts to quit • has withdrawal symptoms when they try to quit (shaky hands, sweating, irritability, or rapid heart rate) • must smoke or chew after every meal or after long periods of time without using, such as after a movie or work meeting • needs tobacco products to feel “normal” or turns to them during times of stress • gives up activities or won’t attend events where smoking or tobacco use is not allowed • continues to smoke despite health problems Signs of addiction Varenicline brand names • agonist at nicotinic receptors • acts on mesolimbic dopamine system associated with nicotine addiction, where it prevents nicotine stimulation • stimulates nicotine activity but to lesser degree than nicotine does pharmacology Varenicline • Insomnia • Nausea • Vomiting • Headache • Nasopharyngitis • Application site pruritus side effects Varenicline • Take dose after eating with full glass of water • Days 1 to 3: 0.5 mg orally once a day • Days 4 to 7: 0.5 mg orally 2 times a day • Days 8 to end of treatment: 1 mg orally 2 times a day • Duration of therapy: 12 weeks dosage and usage Varenicline • The patient should set a date to stop smoking. • Dosing should start 1 to 2 weeks before this date OR the patient may begin treatment and quit smoking between Days 8 and 35. • In smoking cessation therapy, risk for relapse to smoking is elevated in the period immediately following the end of treatment. dosage and usage Varenicline • Documented hypersensitivity or skin reactions to drug or components of formulation • Nonsmokers • There are no controlled data in human pregnancy. contraindications Varenicline ? Tafenoquine: increases the level of effect of varenicline Cimetidine: increases levels of varenicline by decreasing renal clearance drug interactions Varenicline • The most common reasons given for discontinuing the medication were the side effects. No significant difference was determined between the groups in respect of the sideeffects observed http://www.tobaccoinduceddise ases.org/A-comparison-of-the- efficacy-of-varenicline-and- bupropion-and-an-evaluation- of-the,69719,0,2.html • Studies confirmed that varenicline is more efficacious than bupropion for smoking cessation https://www.ncbi.nlm.nih.gov/p mc/articles/PMC4824380/ statistic Varenicline https://www.pfizerpro.com/product/chantix/hcp/efficacy statistic Varenicline brand names Bupropion phamacology Bupropion • antidepressant medication used to treat major depressive disorder and seasonal affective disorder • used to help people stop smoking by reducing cravings and other withdrawal effects • structurally unrelated to SSRIs, TCAs, MAOIs • does not inhibit the activity of monoamine oxidase or the reuptake of serotonin • norepinephrine dopamine reuptake inhibitor; may act through dopaminergic or noradrenergic pathways side effects Bupropion • Headache (25 – 34 %) • Dry mouth (17 – 28 %) • Nausea (1 – 18 %) • Weight loss (15 – 20 %) • Insomnia (11 – 20 %) • Agitation (2 – 32 %) • Dizziness (6 – 22 %) • Pharyngitis (3 – 13 %) dosage and usage Bupropion for smoking cessation Zyban: 150 mg PO qDay for 3 days THEN Increase to 150 mg q12hr • should continue treatment for 7-12 weeks • if patient successfully quits after 7-12 weeks, consider ongoing maintenance therapy based on individual patient risk/benefit Dosing considerations (Smoking Cessation) • Begin therapy 1 week before target quit date (usually second week of treatment) • May be used in combination with nicotine patch (NRT) contraindications Bupropion • Hypersensitivity to bupropion or other ingredients • History of anorexia/bulimia; patients undergoing abrupt discontinuation of ethanol or sedatives including anticonvulsants, barbiturates, or benzodiazepines • Coadministration of any other medications that contain bupropion, because seizures are dose dependent • Pregnancy category: C • Lactation: enters breast milk; use caution drug interactions Bupropion • eliglustat: bupropion increases levels of eliglustat by affecting hepatic enzyme CYP2D6 metabolism. Contraindicated. • isocarboxazid: and bupropion both increase dopaminergic effects. Contraindicated. • phenelzine: and bupropion both increase dopaminergic effects. Contraindicated. • pimozide: bupropion increases levels of pimozide by affecting hepatic enzyme CYP2D6 metabolism. Contraindicated. • rasagiline: and bupropion both increase dopaminergic effects. Contraindicated. • selegiline: and bupropion both increase dopaminergic effects. Contraindicated. • selegiline transdermal: and bupropion both increase dopaminergic effects. Contraindicated. • tranylcypromine: and bupropion both increase dopaminergic effects. Contraindicated. • Nicotine Replacement Therapy • a medication that provides a low level of nicotine, without the tar, carbon monoxide and other poisonous chemicals present in tobacco smoke. NRT what does it use for? • Binds to central nervous system (CNS) and peripheral nicotine cholinergic receptors • Works by reducing physical craving for nicotine • Allows patient to focus on behavioral and psychological aspects of tobacco cessation NRT mechanism • Recent myocardial infarction (MI) within past 2 weeks • Serious arrhythmia • Unstable angina NRT precautions • Mouth soreness • Dyspepsia • Hiccups Not recommended: • Smokeless tobacco users • Smokers using fewer than 10 cigarettes per day • Adolescents • Pregnancy NRT side effects Nicotine gum Amount > 25 cigarettes per day: 4 mg, 1 piece every 1-2 hours for first 6 weeks < 25 cigarettes per day: 2 mg, 1 piece every 1-2 hours for first 6 weeks, then begin tapering Directions for chewing • Chew slowly • Stop chewing after noticing peppery taste or tingling sensation • Store in between cheek and gum Cost: $$$ NRT dosage and usage https://www.youtube.com/watch?v=I4HiTBAxzq0 NRT Nicotine gum Advantages and disadvantages • Allows good control of nicotine dose • Some people do not like the taste • Unsuitable for people with dentures Nicotine gum Nicotine lozenges Amount • Based on time of first cigarette of day • If cigarette within 30 minutes of waking, use 4-mg lozenge • Dosing forms 2 mg and 4 mg Directions • Use every 1-2 hours for first 6 weeks, then tapering to every 2-4 hours Cost: $$$ NRT dosage and usage https://www.youtube.com/watch?v=4m-t0VaPdBE NRT Nicotine lozenges Advantages and disadvantages • Discreet and flexible, good control • Nicotine is absorbed through the lining of the mouth, offering good control Nicotine lozenges Nicotine sublingual tablet Amount • You can use one or two tablets each hour (one if you normally smoke 20 or fewer cigarettes a day, two if you normally smoke more than this amount). Directions • Place the sublingual tablet under your tongue and allow it to dissolve slowly. This allows the nicotine from the tablet to be absorbed into your bloodstream from the lining of your mouth. • Do not chew or swallow the tablets. • Do not use more than 40 tablets each day. If you are trying to quit smoking completely, use the tablets for around three months before you gradually reduce using them. NRT dosage and usage Nicotine sublingual tablet Side effects: • nausea, vomiting, drowsiness, dizziness, confusion, constipation, dry mouth, headache, tired feeling, or white patches or sores inside your mouth or on your lips. NRT Advantages and disadvantages • Discreet and flexible, good control • Nicotine is absorbed through the lining of the mouth, offering good control Nicotine sublingual tablet Nicotine nasal spray Amount • Start with 2 sprays, one squirt in each nostril Directions • One squirt in each nostril, using 1-2 doses every hour, (maximum dosing - 5 doses per hour) Side effects • Hot peppery taste • Sneezing , Cough • Watery eyes • Runny nose Cost: $$$ NRT dosage and usage https://www.youtube.com/watch?v=kWak4pc2qyo NRT Nicotine nasal spray Advantages and disadvantages • Fast acting, rapid delivery of nicotine similar to cigarettes • Good for heavy smokers • Can cause nose and throat irritation, coughing, and watering eyes Nicotine nasal spray Nicotine inhaler Amount • Delivers 4 mg of nicotine Directions • Start with 6 cartridges daily for first 3-6 weeks • Maximum: 16 cartridges daily • Recommended for up to 3 months Side effects: • Cough, Headache, Rhinitis, Dyspepsia, Mouth irritation Cost: $$$ NRT dosage and usage https://www.youtube.com/watch?v=aoAvKh0Rc3c NRT Nicotine inhaler 0.35- 3.10 Advantages and disadvantages • Good for people who miss the ritual of smoking Nicotine inhaler Nicotine patch Amount Dosing forms: 7, 14, and 21 mg < 10 cigarettes per day: start with 14-mg patch for 6 weeks, decreasing to 7 mg for additional 2 weeks > 10 cigarettes per day: start with 21-mg patch for 6 weeks, reducing to 14 mg for 2 weeks, and 7 mg for 2 weeks Directions • Apply to upper body/upper outer part of arm Side effects: • Localized itching burning and tingling, abnormal dreaming Cost: $$ NRT dosage and usage https://www.youtube.com/watch?v=mznlQQFAsiM NRT Nicotine patch 1.40-3.00 Advantages and disadvantages • Discreet and easy to use • Sustained release can provide extended coverage • May help with early morning cravings • 24 hour patches may disturb sleep • Does not mimic the highs and lows associated with nicotine Nicotine patch