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Continuing Education for PharmacistsMedications for the Treatment of Nicotine AddictionThis CPE lesson was written by Nazifa Obaidi, 2010 Pharm.D. Candidate, University of Nebraska College of Pharmacy, who has nofinancial or conflict of interest disclosures. background information on thehealth impact of tobacco use, the Current Therapy
Mechanism of Action. Varenicline is
Objectives
action. Varenicline stimulates low-level agonist activity and Introduction
According to The Clinical Practice Guidelines for Treating Tobacco Use Dosing/Administration. Varenicline
have been declining since the 1950s.
Partial Nicotinic Receptor
Angonists
Varenicline (Chantix®) Chantix® is
Pharmacokinetics. Varenicline is
Adverse Effects. The most common
Advantages. Relief from nicotine
Drug Interactions. No clinically
Psychotropes
Bupropion Sr (Zyban®) Bupropion
SR, initially approved as an atypical
Pharmacokinetics. Bupropion SR is
Contraindications/Precautions.
Mechanism of Action. The exact
Adverse Effects. Common adverse
Dosing/Administration. Bupropion
prior to the chosen smoking quit-day.
Nicotine Replacement Therapy
Drug Interactions. Although the
(NRT) The aim of NRT is to
caution in active peptic ulcer disease.
SR is utilized, it can cause a clinically Drug Interactions. Nicotine has
chest pain and heart rate and adecrease in blood pressure. NRT and Contraindications/Precautions.
Mechanism of Action. Nicotine has
Contraindications/Precautions.
Advantages. Bupropion SR can delay
is associated with smoking cessation.
Nicotine Transdermal Patch
(Nicoderm CQ®, Habitrol®,
Usage for nicotine Gum7,8
ProStep®, Nicotrol®) Transdermal
patches were FDA-approved inNovember 1991 and are available Dosing/Administration.
Transdermal patches are available in
elimination half-life of 3 to 4 hours.8,9 Nicotine Polacrilex Gum
(Nicorette®) Nicorette® was
Adverse Effects. Among the most
Dosing/Administration. Nicotine
folding the patch onto itself. Nicotrol® Contraindications/Precautions.
Pharmacokinetics. Nicotine is well
with a maximum of 24 pieces per day.
the extent of absorption is not known.
Advantages. One advantage of
"parked" inside the mouth between the cheek and gum until the tingle orpeppery taste fades. This process Dosing for nicoDerm CQ®
Transdermal Patch8
swallowed. It is recommended to useat least 9 pieces of gum per day for Light Smoker
Heavy Smoker
(≤10 cigarettes/day)
(>10 cigarettes/day)
the likelihood of quitting. Certainacidic foods and beverages like coffee, Pharmacokinetics. Peak nicotine
Contraindications/Precautions.
Adverse Effects. Common side
Advantages. It is claimed that the
Contraindications/Precautions. It
Oral Inhaler (Nicotrol®)
effectiveness of the nicotine lozenge.
Dosing/Administration. Nicotrol®
Advantages. Nicotine gum is a short
Pharmacokinetics. Nicotine from
Nicotine Polacrilex Lozenge
(Commit®) Nicotine lozenge
Dosing/Administration. Nicotine
Adverse Effects. Common adverse
Pharmacokinetics. After oral
Pharmacokinetics. After nasal
Adverse Effects. The most common
adverse effects from the oral inhalerare mouth and throat irritation and Adverse Effects. Common adverse
Advantages. The inhaler formulation
Advantages. More rapid delivery of
Nasal Inhaler (Nicotrol® NS)
Dosing/Administration. Nicotrol®
Clinical Trials/Comparison
Second Line Drugs
abstinence rates in clinical trials after weekly transdermally for 3 to 6 weeks.
Odds ratios of abstinence with first- and
second-line smoking cessation therapy6,14
cessation, outweigh the risks to thefetus. Spontaneous abortion has been Therapies
Odds ratio (95% CI/# of trials)
reported in pregnant women onNRT. Nicotine patches, lozenges, first-line
Pipeline
NicVAX® is a nicotine conjugate
Second-line
cessation aid as well as an aid toprevent relapses. NicVAX® is a positive stimulus caused by nicotine.
at a dose of 25 mg daily. Graduallytitrate to 75 mg to 100 mg daily and Medication Guidelines21
Dose should be tapered prior todiscontinuation of medication.
Common adverse effects associatedwith nortriptyline therapy are The nicotine patch + the nicotine inhaler Selective serotonin re-uptake inhibitors (SSRIs) Pregnancy
medical advice before initiating anysmoking cessation effects of cigarette smoking on thefetus have been well established,including low birth weight, anincreased risk of spontaneous combination smoking cessationtherapies as well as medications not Conclusion
cause of premature mortality andmorbidity in the world. With the cessation guidelines, those whosmoke 10 or more cigarettes per day The next M&P continuing education references
1. 10 Facts About Tobacco and Second-Hand Smoke. World Health Organization (WHO).
http://www.who.int/features/factfiles/tobacco/en/index.html. Accessed on November 12, 2009.
2. State Tobacco Activities Tracking and Evaluation (STATE) System [serial online]. Accessed on November 5, 2009.
3. Smoking Cessation. American Heart Association (AHA). http://www.americanheart.org/presenter.jhtml?identifier=4731. Accessed onNovember 15 2009.
4. Tobacco. Center for Disease Control (CDC). http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm; Accessed on November 15, 2009.
5. Tobacco Free Initiative. World Health Organization.
http://www.who.int/tobacco/mpower/tobacco_facts/en/index.html. Accessed on November 16, 2009.
6. Nides, M. (2008). Update on pharmacologic options for smoking cessation treatment. The American Journal of Medicine, 121(4 Suppl 1),S20-31.
7. Fiore MC, Jaen MC, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. A Clinical Practice Guideline. Washington, DC:US Dept of Health and Human Services. Public Health Service; 2008.
8. Clinical Pharmacology [internet database]. Tampa, FL: Gold Standard Inc; 2009. http://www.clinicalpharmacology.com: AccessedNovember 16, 2009.
9. Micromedex Healthcare Series [internet database]. Version 5.1. Greenwood Village, Colo.: Thompson Healthcare: Accessed November 16,2009.
10. Gunnell, D., Irvine, D., Wise, L., Davies, C., & Martin, R. M. (2009). Varenicline and suicidal behaviour: A cohort study based on data fromthe general practice research database. BMJ (Clinical Research Ed.), 339, b3805.
11. Zyban prescribing information. http://us.gsk.com/products/assets/us_zyban.pdf; 12. Jorenby, D. E., Hays, J. T., Rigotti, N. A., Azoulay, S., Watsky, E. J., Williams, K. E., et al. (2006). Efficacy of varenicline, an alpha4beta2nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: A randomized controlled trial.
JAMA : The Journal of the American Medical Association, 296(1), 56-63.
13. Quit-smoking products: Boost your chance of quitting for good. MayoClinic. http://www.mayoclinic.com/health/quit-smoking-products/MY00781/NSECTIONGROUP=2: Accessed November 20. 2009.
14. Stead, L. F., Perera, R., Bullen, C., Mant, D., & Lancaster, T. (2008). Nicotine replacement therapy for smoking cessation. CochraneDatabase of Systematic Reviews (Online), (1)(1), CD000146. 15. NicVAX. NABI pharmaceuticals. http://www.nabi.com/pipeline/pipeline.php?id=3; November 2009.
16. Hajek, P., West, R., Foulds, J., Nilsson, F., Burrows, S., & Meadow, A. (1999). Randomized comparative trial of nicotine polacrilex, atransdermal patch, nasal spray, and an inhaler. Archives of Internal Medicine, 159(17), 2033-2038. 17. Smoking Cessation. Rakel: Textbook of Family Medicine, 7th ed. Copyright 2007 Saunders, An Imprint of Elsevier.
18. Shiffman, S., Dresler, C. M., Hajek, P., Gilburt, S. J., Targett, D. A., & Strahs, K. R. (2002). Efficacy of a nicotine lozenge for smokingcessation. Archives of Internal Medicine, 162(11), 1267-1276. 19. Jorenby, D. E., Leischow, S. J., Nides, M. A., Rennard, S. I., Johnston, J. A., Hughes, A. R., et al. (1999). A controlled trial of sustained-releasebupropion, a nicotine patch, or both for smoking cessation. The New England Journal of Medicine, 340(9), 685-691.
20. West, R., McNeill, A., & Raw, M. (2000). Smoking cessation guidelines for health professionals: An update. health education authority.
Thorax, 55(12), 987-999. 21. Treating tobacco use and dependence: 2008 update. Rockville (MD): U.S. Department of Health and Human Services, Public HealthService; 2008 May. http://www.guideline.gov; Accessed on November 20, 2009.
22. Dent, L. A., Harris, K. J., & Noonan, C. W. (2007). Tobacco interventions delivered by pharmacists: A summary and systematic review.
Pharmacotherapy, 27(7), 1040-1051.
• Preventable deaths due to non-adherence are estimated to be at least 125,000 each year. Pharmacists should lead the wayin educating patients about being adherent to their prescribed medication therapy. Vermeire, E., et al. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther. 2001 Oct;26(5):331-42.
• According to one study, people aged 75 years and older take an average of 7.9 drugs per day. Assure your patientsunderstand the importance of being adherent by discussing their medications with them at each visit. Marinker M, Blenkinsopp A, Bond C, et al. From Compliance to Concordance: Achieving Shared Goals in Medicine Taking. London, UK: RoyalPharmaceutical Society of Great Britain; 1997.
• With the increasing number of patients with chronic illnesses, there are increased numbers of prescription medicationsbeing prescribed. Those patients that are on multiple medications are more likely to miss doses and not take theirmedications properly. While the list of reasons for non-adherence is long, pharmacists are on a short-list of healthcareprofessionals that can make a significant impact on this health care crisis. Talk to these patients about ways in order toimprove their medication adherence. • There are many stakeholders in the effort to improve medication adherence and everyone in the health care system has arole to play. Patients are non adherent to medications for a variety of reasons, and need to be educated continuously.
Pharmacists, as the medication experts should be leading the way to ensuring optimal medication use. Being among the mostaccessible members of the health care team, pharmacists are in the position to conduct adherence interventions. • Patients on multiple medications are more likely to miss doses and not take their medications properly. Talk to thesepatients about ways in order to improve their medication adherence. • There are many stakeholders in the effort to improve medication adherence. Pharmacists, as the medication experts shouldlead the way to ensuring optimal medication use. • Everyone in the health care system has a role to play in improving prescription medication adherence. Pharmacists, as themedication experts should lead the way to ensuring optimal medication use. Continuing Education for PharmacistsQuiz and Evaluation Medications for the Treatment of Nicotine Addition 1. What percent of adult Nebraska residents were 6. Which NRT formulation is not FDA-approved in 2. All the following are considered first-line 7. Which of the following is true about the nicotine medications for tobacco cessation except: 3. The most common adverse effect of varenicline is: 8. Dosage of which drug should be adjusted when a 4. When should a patient be instructed to quit b. One to two weeks afterc. One to two months after 9. Nicotine gum, bupropion SR, varenicline, and d. It does not matter when the patient quits clonidine are classified as FDA pregnancy category 5. What nicotine gum dosage regimen should be initiated for a patient who smokes 20 cigarettes per a. 1 piece (2 mg) every 1 to 2 hoursb. 1 piece (4 mg) every 1 to 2 hours 10. (T/F) Currently, there is vaccine being studied for the treatment of tobacco dependence.
J o u r n a l C P E A n s w e r S h e e t
The Georgia Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a providerof continuing pharmacy education. No financial was received for this activity. This article was originally published bythe Nebraska Pharmacists Association under UAN#128-000-10-017-H01-P Participants should not seek duplicatecredit. This article in reprinted with permission from the Nebraska Pharmacists Association.
Medication for the Treatment of nicotine Addiction
This lesson is a knowledge-based CPE activity and is targeted to pharmacists.
GPhA code: J10-08
ACPE#: 0142-9999-10-008-H01-P
Contact Hours: 1.5 (0.15 CEU)
Release Date: 08/01/2010
Expiration Date: 08/01/2013
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