Smoking cessation therapy

Transcription

1 Appendix 1 Smoking cessation therapy Q. Can a dentist prescribe medications for smoking cessation? A. Yes. Dentists are allowed and are encouraged to help patients with smoking cessation by counseling and prescribing smoking cessation medications. Q. Should only one product be recommended or prescribed? A. No. It is recommended to try different agents and combine them including behavioral therapy. Combination drug therapy is usually more effective than monotherapy, particularly for more heavily tobacco-dependent patients. These go-to combinations are nicotine replacement therapy (NRT) plus bupropion (Zyban), or high-dose NRT using a nicotine patch plus nicotine gum or lozenges ( ). Q. Is Nicorette gum sugar-free? A. Yes. Nicorette gum does not contain sugar. Q. What is Chantix? A. Chantix is varenicline, a nicotine receptor partial agonist and the first designer drug for tobacco dependence. One serious adverse effect is increased risk for suicide thoughts and actions. The dentist should know the following about Chantix: (1) patient has had depression or other mental health problems, because these symptoms may worsen while taking Chantix; (2) experienced nicotine withdrawal symptoms with prior quit attempts, with or without Chantix ( quitting smoking, with or without Chantix, can result in nicotine withdrawal symptoms such as depressed mood, agitation or a worsening of existing mental health problems, such as depression; (3) patient has kidney problems or get kidney dialysis (a lower dose may be necessary and obtain a medical consult); (4) patient has a history of heart or blood vessel problems because these problems and any new or worse symptoms can occur while taking Chantix obtain a medical consult; (5) if patient is pregnant or plans to become pregnant; and (6) if patient is breastfeeding ( chantix.com/side-effects-safety-info.aspx?source=google&hbx_pk=s_+chantix+side+effects&hbx_ou=50&o= &skwid = ). Q. What are some medications that the dentist can recommend or prescribe for smoking cessation? A. See Table A1. Q. Can the patient smoke while using the patch or other products? A. No. Smoking while using a nicotine patch or other nicotine products increases the incidence of nicotine overdose. The Dentist s Drug and Guide, First Edition. Mea A. Weinberg and Stuart J. Froum John Wiley & Sons, Inc. Published 2013 by John Wiley & Sons, Inc. 209

2 Appendix 1 Smoking cessation therapy Q. Can a dentist prescribe medications for smoking cessation? A. Yes. Dentists are allowed and are encouraged to help patients with smoking cessation by counseling and prescribing smoking cessation medications. Q. Should only one product be recommended or prescribed? A. No. It is recommended to try different agents and combine them including behavioral therapy. Combination drug therapy is usually more effective than monotherapy, particularly for more heavily tobacco-dependent patients. These go-to combinations are nicotine replacement therapy (NRT) plus bupropion (Zyban), or high-dose NRT using a nicotine patch plus nicotine gum or lozenges ( ). Q. Is Nicorette gum sugar-free? A. Yes. Nicorette gum does not contain sugar. Q. What is Chantix? A. Chantix is varenicline, a nicotine receptor partial agonist and the first designer drug for tobacco dependence. One serious adverse effect is increased risk for suicide thoughts and actions. The dentist should know the following about Chantix: (1) patient has had depression or other mental health problems, because these symptoms may worsen while taking Chantix; (2) experienced nicotine withdrawal symptoms with prior quit attempts, with or without Chantix ( quitting smoking, with or without Chantix, can result in nicotine withdrawal symptoms such as depressed mood, agitation or a worsening of existing mental health problems, such as depression; (3) patient has kidney problems or get kidney dialysis (a lower dose may be necessary and obtain a medical consult); (4) patient has a history of heart or blood vessel problems because these problems and any new or worse symptoms can occur while taking Chantix obtain a medical consult; (5) if patient is pregnant or plans to become pregnant; and (6) if patient is breastfeeding ( chantix.com/side-effects-safety-info.aspx?source=google&hbx_pk=s_+chantix+side+effects&hbx_ou=50&o= &skwid = ). Q. What are some medications that the dentist can recommend or prescribe for smoking cessation? A. See Table A1. Q. Can the patient smoke while using the patch or other products? A. No. Smoking while using a nicotine patch or other nicotine products increases the incidence of nicotine overdose. The Dentist s Drug and Guide, First Edition. Mea A. Weinberg and Stuart J. Froum John Wiley & Sons, Inc. Published 2013 by John Wiley & Sons, Inc. 209

3 210 The dentist s drug and prescription guide Table A1 Pharmacologic agents used for smoking cessation. Product Directions for use Supplied Adverse effects Rx or Nicotine gum Generics Nicorette Do not smoke during treatment because of risk of nicotine overdose. Chew one piece of gum every 1 2 hours for weeks 1 6; every 2 4 hours for weeks 7 9; and every 4 8 hours for weeks Do not eat or drink for 15 minutes before chewing gum, and do not eat or drink while chewing gum. 2 mg, 4 mg gum; starter kit has 108 pieces and refill kits have 48 pieces Mouth soreness, sore jaw, dyspepsia (stomach pain or discomfort), bronchospasm, nausea, vomiting Nicotine transdermal system Generics Nicotine Patch (generic) Nicoderm CQ Nicotrol Habitrol Prostep Do not smoke during treatment because of risk of nicotine overdose. Nicoderm CQ: Use one patch daily; start at 21 mg/ day for 6 weeks, then 14 mg/day for 2 weeks, then 7 mg/day for 2 weeks. Maximum therapy is 3 months. Habitrol: if you smoke >10 cigarettes a day: use 21 mg patch for 4 weeks, then the 14 mg patch for 2 weeks, and the a7 mg patch for 2 weeks. Nicoderm CQ: (28-day supply): 21 mg, 14 mg, 7 mg patches Nicotrol: 15 mg (worn only while awake), 10 mg and 5 mg patches Habitrol: 21 mg, 14 mg, 7 mg Prostep: 22 mg or 11 mg patches Local skin irritation, insomnia (difficulty in sleeping) If you smoke 10 cigarettes a day start with 14 mg patch for 6 weeks, then 7 mg patch for 2 weeks. Treatment ends at 8 weeks. Nicotine lozenge Commit If patient smokes the first cigarette more than 30 minutes after awakening then use 2 mg lozenge; use 4 mg if smoke first cigarette within 30 minutes upon wakening. 2 mg (72 pieces), 4 mg (72 pieces) Xerostomia, indigestion and irritated throat Maximum: not more than 20 lozenges a day. Allow lozenge to dissolve slowly over 20 to 30 minutes, swallow as little as possible (continued)

4 Smoking cessation therapy 211 Table A1 (cont d) Product Directions for use Supplied Adverse effects Rx or Nicorette If the first cigarette is smoked more than 30 minutes after waking up the 2 mg strength is used; if the first cigarette is smoked within 30 minutes after waking up then the 4 mg strength is used. 2 mg lozenge 4 mg lozenge Cardiovascular changes, increased heart rate, dizziness, nausea, vomiting, bronchospasm Weeks 1 to 6: 1 lozenge every 1 to 2 hours. Weeks 7 to 9: 1 lozenge every 2 to 4 hours. Weeks 10 to 12: 1 lozenge every 4 to 8 hours. Nicotine nasal spray Nicotrol NS Start with two sprays in each nostril every hour, which may be increased to 80 sprays per day for heavy smokers; maximum dose: 40 doses/day. maximum therapy is 6 months. Taper after 4 6 weeks. Patient should tilt head back when using the spray product Easy spray delivers 0.5 mg nicotine; available in 10-mL bottles Irritation of nasal mucosa, cough, sneezing, bronchospasm in patients with preexisting asthma Tolerance to adverse effects develops after the first week of using the inhaler. Contraindicated in patients with reactive airway disease (e.g. wheezing or allergic reactions) or chronic nasal disease such as nasal polyps or sinusitis. Rx (prescription only) Nicotine inhalation system Nicotrol Inhaler Less nicotine per puff is released with the inhaler than with a cigarette. Best effect is achieved by frequent continuous puffing for about 20 minutes (that is 6 16 cartridges per day; use 1 cartridge per hour). The recommended treatment is up to 3 months and, if needed, a gradual reduction over the next 6 12 weeks. Total treatment should not exceed 6 months. product Inhaler uses nicotine cartridges (10 mg/ cartridge) that provide about 20 minutes of active puffing, or approximately 80 deep draws Irritation of mouth and throat, cough Contraindicated in patients with reactive airway disease Rx (prescription only) Avoid food and acidic drinks before and drinking use of inhaler (continued)

5 212 The dentist s drug and prescription guide Table A1 (cont d) Product Directions for use Supplied Adverse effects Rx or Oral medications (non-nicotine drugs Zyban (bupropion HCl) (does not contain nicotine) Patient should stop smoking within 2 weeks of start of therapy. Option 1: Initial dose is 150 mg/day for 3 days, THEN 150 mg twice a day (at least 8 hours apart). Option 2: 150 mg every morning (this option has fewer adverse effects and better tolerated). Maximum daily dose is 300 mg. Continue drug therapy for 7 12 weeks after the patient stops smoking and can be maintained up to 6 months. Can be used with nicotine patches. 150 mg sustainedrelease tablets Insomnia, xerostomia, anxiety Contraindicated in seizures, currently using Wellbutrin, eating disorder, alcohol dependence or head trauma. Additionally, blood pressure should be monitored Rx (prescription only) Chantix (varenicline) (does not contain nicotine) FDA-approved in May Not used in patients younger than 18 years old. Caution in patients with renal impairment. Packs: first month: 1 card 0.5 mg 11 tabs and 3 cards 1 mg 14 tabs Bottles: 0.5 mg, 1.0 mg Starting one week before the patient quits smoking. 0.5 mg/day for 3 days then 0.5 mg twice a day (am and pm) for the next 4 days. Then after the first 7 days, 1 mg twice a day Nausea, trouble sleeping, headache, changes in behavior, hostility, agitation, depressed mood, suicidal thoughts or actions No tapering needed. Approved for maintenance up to 6 months. Take after eating and with a full glass of water Do not double the dose if the dose if missed Source: Fiore, M.C., Jaen, C.R., Baker, T.B., et al. (2008) Treating tobacco use and dependence: 2008 update. Clinical practice Guideline. US Department of Health and Human Services, Public Health Service, Rockville, MD, May 2008.

6 Smoking cessation therapy 213 Q. How often is the Nicorette gum used? A. The 2 mg gum (for smokers <25 cigarettes/day) and the 4 mg gum (for smokers 25 cigarettes/day). It is recommended to chew a piece every one to two hours during the first six weeks of quitting (a minimum of nine per day). An additional piece can be used if there is a craving. Not more than 24 pieces should be used in one day. Q. How is the nicotine patch used? A. If the patient smokes more than 10 cigarettes a day: 1. For the first 6 weeks, 21 mg per day. 2. For weeks 7 and 8, switch to a moderate-dosage patch, about 14 mg per day. 3. For weeks 9 and 10, move to a low-dosage patch that delivers 7 mg of nicotine per day ( com/quit-smoking-products/nicoderm-cq-steps.aspx ). If the patient smokes less than 10 cigarettes a day: 1. Begin with 14 mg for 6 weeks 2. Then switch to 7 mg for 2 weeks Q. Are there any adverse effects of nicotine replacement therapy products? A. Yes. ( ) Patch : If increased heartbeat and dizziness occurs it is best to switch to a lower-dose patch. Other adverse effects include skin irritation (medical attention is needed if there is swelling or persistent redness lasting more than 4 days redness at the application site), abnormal dreams, headache, muscle aches, nausea and vomiting. If the patient has a history of heart disease, refer the patient to his/her physician. Gum : Abnormal dreams; diarrhea; difficulty sleeping; dry mouth; joint pain; muscle pain; nervousness, sweating, weakness, mouth, teeth, or jaw problems, allergic reaction, irregular or fast heartbeat, diarrhea, nausea, vomiting. Lozenge : warm or tingling sensation in the mouth, allergic reaction, persistent indigestion, irregular or fast heartbeat, pain, swelling or sores in the mouth. Inhaler : coughing; diarrhea; flu-like symptoms; headache; hiccups; indigestion; mouth or throat irritation; muscle aches; nausea; pain in the jaw and neck; runny nose, taste changes, allergic reaction, irregular or fast heartbeat. Spray : back pain, burning or irritation of the mouth, nose, or eyes, changes in taste and smell constipation, cough, earache, flushing of the face, gas, headache, hoarseness, indigestion, irritability, joint pain, sores in the mouth, ulcers or blisters in the nose, nose bleeding, nausea, runny nose, sneezing; sore throat; stuffy nose, watery eyes, irregular or fast heartbeat, memory loss. Q. Are there any drug interactions with the smoking cessation products? A. The following medications may need dosage adjustment when taking nicotine patch, gum, lozenge, or spray: Acetaminophen (Tylenol) Beta-blockers (atenolol, pindolol, metoprolol, timolol, nadolol, and propranolol) Caffeine (coffee, tea, colas) Furosemide (Lasix) Phenylephrine (Neo-Synephrine) Prazosin (Minipress) Theophylline Tricyclic antidepressants (amitriptyline, nortriptyline, imipramine).