Nicotine Replacement Therapy Inpatient Prescribing Guideline

Transcription

1 SH CP 187 Nicotine Replacement Therapy Inpatient Prescribing Guideline Summary: Nicotine replacement therapy prescribing guideline (does not cover e-cigarettes and similar products) Keywords (minimum of 5): (To assist policy search engine) Nicotine replacement therapy, NRT, smoking, smokefree, smoking ban, smoking abstinence, cigarettes, vape Target Audience: All prescribers, pharmacists, pharmacy technicians, nurses, healthcare support workers, mental health practitioners, occupational therapists. Next Review Date: September 2020 Approved & Ratified by: Medicines Management Committee Date of meeting: 19 th Date issued: November 2018 Author: Gillian Ritchie, Clinical Pharmacist Sponsor: Karl Marlowe, Medical Director 1

2 Version Control Change Record Date Author Version Page Reason for Change 20/03/17 Glenis Clifford 1 9 NRT costs 20/03/17 Francis Johnson 1 5 Added if patient is on, Added 24 and 16 hour patch information, amend the signs 03/05/17 Francis Johnson 1 10 Changed the smoking and interactions with medication table 6/6/17 Gillian Ritchie 1 5 Adjusted the signs alongside the quickmist oral spray and inhalator, to reflect current costings. 6/6/17 Gillian Ritchie 1 10 Changed the smoking and interactions with medication table back to the original version from Version 1 as this is more comprehensive and accurate (and checked it still reflects current evidence). 13/6/17 Gillian Ritchie 1 5 Added the words contraindications, adverse effects of the preparations to the second box from the top, where it states to choose NRT products based on patient preference, level of dependence, previous use of NRT 13/6/17 Gillian Ritchie 1 5 Added the words at least seven days to the sentence advising to avoid using the same site (for nicotine patch) for at least seven days. 13/6/17 Gillian Ritchie 1 5 Added, acidic drinks such as coffee or fruit juice may decrease the absorption of nicotine through the buccal mucosa and should be avoided for 15 minutes before the use of oral NRT. 13/6/17 Gillian Ritchie 1 5 Added care should be taken to avoid spraying into the eyes in the administration section for nicotine oral spray. 13/6/17 Gillian Ritchie 1 5 Added if an adverse event occurs with a high strength lozenge, a lower strength lozenge should be considered instead. If attempting smoking cessation, treatment should continue for 6 12 weeks before attempting a reduction in dose. Use beyond 6 months is generally not recommended in the nicotine lozenge section. 13/6/17 Gillian Ritchie 1 5 Added until the taste becomes strong. The lozenge should then be lodged between the gum and the cheek. When the taste fades, the lozenge should be sucked again this should be repeated until the lozenge dissolves completely. To the administration section for the nicotine lozenge. 13/6/17 Gillian Ritchie 1 5 Added place the cartridge in the device to the administration section for nicotine inhalation cartridge. 13/6/17 Gillian Ritchie 1 5 Deleted suggest the patient experiments with what suits them best, eg 5 or 10 minute inhalation periods and replaced it with each session can last for approximately five minutes. 13/6/17 Gillian Ritchie 1 5 Deleted note that a bottle of Quickmist spray lasts for approximately 72 hours and so one bottle may be given to the patient every 72 hours if necessary and replaced it with: note that a bottle of Quickmist spray contains at least 150 sprays. The maximum dose is 64 spays in 24 hours. 13/6/17 Gillian Ritchie 1 11 Added and / or who have uncontrolled hypertension to the section on cardiovascular / cerebrovascular disease. 13/6/17 Gillian Ritchie 1 11 Added and obstructive lung disease to the section on lung disease. 13/6/17 Gillian Ritchie 1 11 Added sections regarding precautions for using NRT in people with seizures, broken skin / skin disorders and atopic or eczematous dermatitis. 13/6/17 Gillian Ritchie 1 12 Added increased salivation and blurred vision to the side effects table. 13/6/17 Gillian Ritchie 1 All Added references throughout guideline. 13/6/17 Gillian Ritchie 1 All Reviewed entire guideline to ensure it reflects current evidence. 19/6/17 Gillian Ritchie 1 5 Deleted the words choose one with respect to use of short-acting NRT preparations 10/07/17 Gillian Ritchie 2 8 Added the Melbury Lodge record. 11/09/17 Alex Weston 2 5 Added text restricted use, not to be used for new patients from Oct 1 st /09/17 Alex Weston 2 6 Removed Quick Mist spray from chart and added as 2b on page 7 20/09/17 Alex Weston 2 5 Added 6 months maximum supply of NRT products 25/7/18 Rebecca Henry 3 Through out Melbury Lodge changed to EPMA sites Nicotine inhalator, not to be used a t leigh House Only 16 hours patch to be used at leigh House Melbury lodge discretionary meds paper chart removed Order details added Add if using e cigarettes or vapes to avoid prescribing short acting preparations 2

3 Reviewers/contributors Name Position Version Reviewed & Date Gillian Ritchie Pharmacist V1 December 2015 Vanessa Lawrence Principal pharmacist V1 December 2015 Sue Mills Chief Pharmacist V1 December 2015 Marion Wetherill Principal Pharmacist V1 December 2015 All AMH Consultant Psychiatrists V1 December 2015 All Consultant Forensic Psychiatrists adult V1 December 2015 Mental health drugs and therapeutics committee V1 December 2015 Julia Robson Clinical Service Manager- Quit4life V1 December 2015 Wendy Bennett Operational Service Manager Quit4life V1 December 2015 Glenis Clifford Clinical Lead Quit4Life Version 1 March 2017 Francis Johnson Deputy Chief Pharmacist Version 1 March 2017 Rebecca Henry Principal Pharmacist Specialised Version 1 March 2017 and Training Gillian Ritchie Clinical Pharmacist Version 1 June 2017 Ishtiaq Hussian Specialist registrar, Leigh House Sept

4 Contents Section Title Page 1. Nicotine replacement therapy prescribing algorithm 5 2. As required short-acting nicotine replacement therapy prescription and administration chart Nicotine replacement therapy products and prices 8 4. Ordering process 9 5. Smoking and interactions with medication (discussion) Smoking and interactions with medication (table) Precautions for use of NRT Side effects of NRT Use of NRT in pregnancy / lactation References 14 4

5 1. Nicotine replacement therapy prescribing algorithm SHFT will supply NRT products for a maximum of 6 months Assess level of nicotine dependence. Consider: How many cigarettes a day does the person usually smoke? Patient choice of NRT product How soon after waking does the person have his / her first cigarette? Known allergies to NRT products Previous use of NRT Current medical conditions If patient is on clozapine, obtain level and adjust dose as per Trust clozapine guideline (CP 114) (1). Check GASS for clozapine and increase physical observations. Refer to appendix 8 of this guideline for details of dose adjustments required for other medication when stopping / abstaining from smoking Choose NRT products based on patient preference, level of dependence, previous use of NRT, contraindications, adverse effects of the preparations, nicotine withdrawal and cravings (2) Light smoker Smokes fewer than 10 cigarettes daily Moderate / heavy smoker Smokes more than 10 cigarettes daily (2, 3, 4, 5) Nicotine patch 14mg / 24 hours for 6 8 weeks then 7mg / 24 hours for 2 4 weeks OR 15mg / 16 hours Invisi patch for 6 8 weeks then 10mg / 16 hours Invisi patch for 2 4 weeks (2, 3, 4, 5) Nicotine patch 21mg / 24 hours for 6 8 weeks then 14mg / 24 hours for 2 weeks then 7mg / 24 hours for 2 weeks OR 25mg / 16 hours Invisi patch for 8 weeks then 15mg / 16 hours Invisi patch for 2 weeks then 10mg / 16 hours Invisi patch for 2 weeks NOTE: if a patient is abstaining from smoking only for the duration of his / her hospital stay (rather than stopping smoking long-term), it would be appropriate for him / her to continue on the higher dose patch whilst in hospital, and not to attempt the reducing dosage regimen detailed above. Apply the patch on waking to dry, non-hairy skin on the hip, trunk or upper arm (2, 3, 4, 5, 6). Hold in position for seconds to ensure adhesion (2) For the 24 hour patch: Remove the patch the following day and place a new patch on a different area (2, 3, 4, 5). Avoid using the same site for at least seven days (2, 3, 4, 5, 6). For the 16 hours patch: Apply on waking in the morning and remove at bedtime (2). Avoid using on the same site for several days. Leigh House to only use the 16hour patches and only for 12 weeks If the person experiences strong cravings for cigarettes upon waking, a 24 hour patch may be more suitable (2) If withdrawal symptoms are experienced, the strength of the patch should be maintained or increased until the patient is stabilised (2). If a patient using the high-strength patch experiences excessive side effects that do not resolve within a few days, he / she should be changed to a medium-strength patch for the remainder of the initial treatment period and then use the lower strength patch for 2 4 weeks (2, 3, 4, 5, 6). Monitor and review on an ongoing basis to ensure effectiveness. Combine with a short-acting preparation Not to be prescribed if the patient is using electronic cigarettes or vapes Acidic drinks such as coffee or fruit juice may decrease the absorption of nicotine through the buccal mucosa and should be avoided for 15 minutes before the use of oral NRT (2). Nicotine lozenge 1mg / 2mg / 4mg Dose: One lozenge every 1 2 hours when the urge to smoke occurs (2, 10, 11). Max 15 lozenges / 24 hours. Individuals who smoke fewer than 20 cigarettes daily should use the lower strength lozenges (2, 10). Individuals who smoke more than 20 cigarettes daily and those who fail to stop smoking with the low-strength lozenges should use 4mg lozenges (2, 11). For all other individuals, the 1mg or 2mg lozenges should be used. If an adverse event occurs with a high strength lozenge, a lower strength lozenge should be considered instead (10). If attempting smoking cessation, treatment should continue for 6 12 weeks before attempting a reduction in dose (BNF). Use beyond 6 months is generally not recommended (10). Administration: Allow the lozenge to dissolve slowly in the mouth until the taste becomes strong (10, 11). The lozenge should then be lodged between the gum and the cheek (10, 11). When the taste fades, the lozenge should be sucked again (10, 11). From time to time, move the lozenge from one side of the mouth to the other (2). This routine should be repeated until the lozenge dissolves completely (10). Try not to swallow excessively as the nicotine needs to be absorbed through the buccal mucosa. Lozenges last for minutes (2, 10). OR Nicotine inhalation cartridge., not to be used at Leigh House Dose: Max 6 cartridges / 24 hours Administration: Place the cartridge in the device and draw in air through the mouthpiece (2). Each session can last for approximately five minutes (2). The amount of nicotine from one puff of the cartridge is less than that from a cigarette (2, 12). Therefore it is necessary to inhale more often than when smoking a cigarette (2). A 15mg cartridge lasts for approximately 40 minutes of intense use (2, 12). One cartridge 4 6 normal strength cigarettes. OR Nicotine Oral spray (Quickmist mouthspray) restricted use, not to be used for new patients from Oct 1 st Particularly good for heavier smokers - faster onset of action compared with other products. Dose: 1 2 sprays in the mouth (up to 4 sprays / hour) when the urge to smoke occurs or to prevent cravings (2, 9). Max 64 sprays / 24 hours Administration: The oral spray should be released into the mouth, holding the spray as close to the mouth as possible (9) and avoiding the lips (2). Release one spray into the side of the mouth. The patient should not inhale while spraying and should avoid swallowing for a few seconds after use (2, 9). If using the spray for the first time, or if it has not been used for 2 or more days, prime the unit before use (2) (point the spray away from the user or other people and press the top of the device 3 times until a fine spray appears) (9) Care should be taken to avoid spraying into the eyes (9). (7, 8) 5

6 2a. As required short-acting nicotine replacement therapy prescription and administration chart (EPMA sites USE JAC ELECTRONIC PRESCRIBING SYSTEM, SEE BELOW) Ward Allergy / sensitivity Clinician s signature Date Surname First name Consultant Date of birth If none known, endorse NKDA Patient s NHS number Prescribe a nicotine patch on the main prescription chart. Prescribe ONE of the following short-acting nicotine replacement products on an as required basis, and cross through the other product. Following an individual risk assessment, patients may be given up to 24 hours supply of prn NRT as per MCAPP (CP1). It should be labelled with the patient s name and may be kept on the patient for self-administration. The quantity given should be documented below in addition to the date/time/initials Nicotine lozenge Dose interval (minimum) 1 2 hours OR Nicotine inhalation cartridge Dose interval (minimum) 1 2 hours Dose 1mg / 2mg / 4mg (circle) Route Oral Max 15 lozenges in 24 hours Dose 15mg Route Oral Signature Date Signature Date Max 6 cartridges in 24 hours Date Time Dose Initial Date Time Dose Initial 6

7 2b. As required short-acting nicotine replacement therapy prescription and administration chart, Quickmist Spray (EPMA sites USE JAC ELECTRONIC PRESCRIBING SYSTEM, SEE BELOW ) Restricted use, not to be used for new patients from Oct 1 st 2017 Ward Allergy / sensitivity Clinician s signature Date Surname First name Consultant Date of birth If none known, endorse NKDA Patient s NHS number Note that a bottle of Quickmist spray contains at least 150 sprays (9). The maximum dose is 64 sprays in 24 hours. Prescribe a nicotine patch on the main prescription chart. Following an individual risk assessment, patients may be given up to 24 hours supply of prn NRT as per MCAPP (CP1). It should be labelled with the patient s name and may be kept on the patient for self-administration. The quantity given should be documented below in addition to the date/time/initials. Nicotine oral spray (Quickmist ) Dose interval (minimum) Max 4 sprays / hour Dose Route Max 64 sprays in 24 hours 1 2 sprays Oral Signature Date Date Time Dose Initial Date Time Dose Initial 7

8 3. Nicotine replacement therapy products and prices I N C R E A S I N G C O S T Product Strength Pack size Cost per patient per month Niquitin CQ 24 hour patches Nicorette Invisi 16 hour patches 7mg 1 x mg 1 x mg 1 x mg 1 x mg 1 x mg 1 x Product Strength Pack size Cost per patient per month Lozenges 1mg, 2mg and 4mg 1 x Inhalator cartridges 15mg 1 x Quickmist spray 1mg 1 x 150 dose

9 4. Ordering Item code description Purchase price Contract number Category code Category Description Comments NICORETTE ICY MINT LOZENG 2MG (Outer pack of 4 packs of 80) SH0490 ZOR NICORETTE ICY MINT LOZENG 4MG (Outer pack of 4 packs of 80) SH0490 ZOR Lower strength lozenge. These are the most popular lozenge with clients - most palatable Higher strength lozenge. These are the most popular lozenge with clients - most palatable. Most clients will start on higher strength so probably need more of these NICORETTE INHALATOR 15MG WHITE (Outer pack of 12 packs of 4) SH0490 ZOR NICORETTE INHALATOR 15MG WHITE (Outer pack of 6 packs of 36) SH0490 ZOR Starter pack - clients to try product without wasting large box. Can be also be used if client needs a new mouth piece. May want small stock for ongoing use NICORETTE INVISI PATCH 10MG (Outer pack of 6 packs of 7) 16 hour patch SH0490 ZOR NICORETTE INVISI PATCH 15MG (Outer pack of 6 packs of 7) 16 hour patch SH0490 ZOR NICORETTE INVISI PATCH 25MG (Outer pack of 6 packs of 14) 16 hour patch SH0490 ZOR NIQUITIN PATCH STEP 1 21MG CLEAR (Outer pack of 3 packs of 1 X 14 Days) 24 hour patch SH0490 ZOR NIQUITIN PATCH STEP 2 14MG CLEAR (Outer pack of 6 packs of 1 x 7 Days) 24 hour patch SH0490 ZOR NIQUITIN PATCH STEP 3 7MG CLEAR (Outer pack of 6 packs of 1 x 7 Days) 24 hour patch SH0490 ZOR Few clients will use this strength, may want small stock Some clients will use this strength along side oral product or e-cig MAIN 16 HOUR CLEAR PATCH for most clients to start with and use along side oral product or e-cig. For ongoing use MAIN 24 HOUR clear PATCH for most clients to start with and use along side oral product or e-cig. For ongoing use Some clients will use this strength along side oral product or e-cig Few clients will use this strength, may want small stock 9

10 5. Smoking and interactions with medication Tobacco smoke contains polycyclic aromatic hydrocarbons that induce certain hepatic enzymes (most notably CYP1A2) (13). For some drugs smoking significantly reduces plasma levels of affected medications (13). Therefore higher doses of those medications are needed in people who smoke, compared with people who do not smoke (13). When someone stops smoking enzyme activity reduces over the course of a week (13). It is important to note that NRT does not have any effect on this process (13). Plasma levels of the affected medications will then rise, sometimes substantially (13). Therefore dose reductions are usually necessary (13). If the person restarts smoking, enzyme activity increases, plasma levels of the affected medications fall and hence, dose increases are required (13). This process is complicated and additionally so as the effects are difficult to predict (13). Further complexity is introduced by intermittent smoking (13). Close monitoring of plasma levels, clinical progress and adverse effects is essential (13). Some of the medications that could be affected by a patient stopping smoking (or temporarily abstaining from smoking) are listed in the table on the following page (adapted from The Maudsley Guideline, 12 th edition (13) ). This is not an exhaustive list of medications affected by smoking. Please contact your ward pharmacist for further details. When someone changes their smoking status or alters the number smoked or when medications are started / stopped, it is important to liaise closely with the patient s prescriber in hospital and in the community. 10

11 (13, 14) Smoking and interactions with medication (This list is not exhaustive. Discuss with your ward pharmacist for more information) Drug Effect of smoking Action to be taken on stopping smoking Action to be taken on re-starting smoking Agomelatine Plasma levels decreased Monitor closely. May need to decrease dose. Consider re-introducing previous smoking dose. Aminophylline / theophylline Levels decreased. Obtain level. Consider decreasing dose by 25 33% after one week. Anticipate the need for further dose reductions over future weeks / months. Monitor closely. May need to decrease dose. Monitor closely. Consider decreasing dose by up to 25% over one week. Monitor for changes in severity of adverse effects. Obtain level. Adjust dose as necessary and monitor closely. Beta blockers Effect of beta blockers decreased. Monitor closely. May need to adjust dose. Benzodiazepines Plasma levels decreased by Monitor closely. Consider restarting 0 50%. previous smoking dose. Carbamazepine Levels may be decreased to Monitor plasma levels. a small extent. Chlorpromazine Levels decreased. Monitor closely. Consider decreasing dose. Monitor closely. Consider restarting previous smoking dose. Clozapine Plasma levels decreased by Obtain clozapine level before stopping. On Obtain level before restarting. up to 50%. Effect may be stopping, decrease dose gradually over a Increase dose to previous smoking greater if co-prescribed week by 25%. Repeat level one week after dose over one week. Repeat level valproate. stopping. Anticipate further dose reductions. after one week on new dose. Duloxetine Levels may be decreased by up to 50%. Monitor closely. Dose may need to be decreased. Flecainide Decreases flecainide levels. Monitor for flecainide adverse effects (eg, dizziness, nausea, tremor). May need to decrease flecainide dose. Fluphenazine Levels decreased by up to Decrease dose by 25%. Monitor carefully 50%. during the next 4 8 weeks. Consider Fluvoxamine Haloperidol Mirtazapine Olanzapine Opioids, including methadone Theophylline / aminophylline Tricyclic antidepressants Levels decreased by approx one third. Levels decreased by approx 20%. Unclear, but effect probably minimal. Levels decreased by up to 50%. Opioid effectiveness decreased. Levels decreased. Levels decreased by 25 50%. further dose reductions. Monitor closely. May need to decrease dose. Decrease dose by approx 10%. Monitor carefully. Consider further dose reductions. Monitor. Obtain level before stopping. On stopping, decrease dose by 25%. After one week, repeat plasma level. Consider further dose reductions. Monitor for adverse effects and signs of opioid toxicity. Consider decreasing the dose. Obtain level. Consider decreasing dose by 25 33% after one week. Anticipate the need for further dose reductions over future weeks / months. Monitor closely. Consider decreasing dose by 10 25% over one week. Consider further dose reductions. Consider re-introducing previous smoking dose. Monitor closely. May need to increase flecainide dose to previous smoking dose. Increase dose to previous smoking dose. May need to increase dose to previous smoking dose. Increase dose to previous smoking dose. Monitor. Obtain level before restarting. Increase dose to previous smoking dose over one week. Repeat plasma level. Monitor for effectiveness. Consider increasing the dose gradually. Obtain level. Adjust dose as necessary and monitor closely. Monitor closely. Consider restarting previous smoking dose. Warfarin INR may be decreased. Monitor INR closely. May need to alter dose. Monitor INR closely. May need to alter dose. Zuclopenthixol Unclear, but effect probably minimal. Monitor. Monitor. 11

12 6. Precautions for use of NRT Cardiovascular / cerebrovascular disease: Patients in hospital with a myocardial infarction, severe arrhythmia or stroke and who are haemodynamically unstable and / or who have uncontrolled hypertension, should be encouraged to stop smoking without NRT (3, 4, 5, 6, 9). If this fails, these patients should be offered NRT under medical supervision (3, 4, 5. 6, 9, 10, 11, 12). Diabetes: Blood glucose levels may destabilise when stopping smoking or abstaining from smoking 9, 10, 15). This is because catecholamines released by nicotine can affect carbohydrate metabolism 10, 15). Blood glucose levels should be monitored closely when using NRT (2, 3, 4, 5, 6, 10, 11, 15). Renal and hepatic impairment: NRT should be used with caution in patients with moderate / severe hepatic impairment and / or severe renal impairment (9, 10). This is because the clearance of nicotine or (3, 4, 5, 6, 9, its metabolites may be decreased, thereby potentially leading to an increase in adverse effects 10, 11). Gastrointestinal disease: Swallowed nicotine (from swallowed spray, lozenges or inhalator) may exacerbate oesophagitis, gastritis, gastric or peptic ulcers, oral or pharyngeal inflammation (9, 10, 11, 12). Oral NRT preparations should be used with caution in patients with these conditions (2, 9, 10, 11, 12). Phaeochromocytoma and uncontrolled hyperthyroidism: NRT should be used with caution in patients with these conditions as nicotine causes the release of catecholamines (4, 5, 6, 9, 10, 11, 12, 15). Lung disease: Patients with obstructive lung disease may find the inhalator difficult to use. A nicotine patch, oral spray or lozenge may be preferred. Nicorette inhalator should be used with caution in patients with chronic throat disease, bronchospastic disease and obstructive lung disease (2). Seizures: Potential risks and benefits of nicotine should be carefully evaluated before use in patients taking antiepileptics or in those with a history of epilepsy, as convulsions have been reported in association with nicotine (3, 4, 11). Broken skin /skin disorders: NRT patches should not be placed on broken skin (2, 3, 4), and they should not be used by patients with skin disorders (2, 5, 6, 7). Atopic or eczematous dermatitis (due to localised patch sensitivity): In the case of severe or persistent local reactions at the site of application (eg, severe erythema, pruritus or oedema) or a generalised skin reaction (eg urticarial, hives or generalised skin rashes) nicotine patches should be discontinued and medical review obtained (3, 4, 5, 6, 7). Most warnings for NRT also apply to continued cigarette smoking (2). However, the risk of continued smoking outweighs any risks of using NRT preparations (2). (3, 4, (2, 3, 4, 12

13 7. Side effects of NRT products (2, 3, 4, 5, 6, 9, 11, 15) This list is not exhaustive. Please refer to the relevant manufacturer s data sheet ( or the BNF for a more complete list for each product. Patch (adverse Oral spray Lozenge Inhalator effects common in first 2 3 weeks) Urticaria Itching Burning, tingling, numbness Swelling Pain Interference with taste Headache Hiccups Throat / mouth /tongue irritation Dry mouth Burning lips Indigestion Nausea Increased salivation Blurred vision 8. Use of NRT in pregnancy / lactation Please refer to your ward pharmacist prior to prescribing / administering NRT to a patient who is pregnant or lactating. It is important that current advice is obtained from specialist reference sources. 13

14 9. References 1) Southern Health NHS Foundation Trust Clozapine Guideline SH CP 114 Version 2 (October 2016) Accessed 13 th June ) Royal Pharmaceutical Society and British Medical Association British National Formulary 72 September 2016 March ) data sheet NiQuitin 14mg transdermal patch 4) data sheet NiQuitin 7mg transdermal patch 5) data sheet Nicorette Invisi 15mg patch 6) data sheet Nicorette Invisi 25mg patch 7) NICE guideline PH48 Smoking: acute, maternity and mental health services (November 2013) 8) NICE Public Health guideline PH10 Stop Smoking (November 2013) 9) data sheet Nicorette quickmist oral spray 1mg 10) data sheet Nicotinell mint lozenges 2mg 11) data sheet NiQuitin minis mint lozenges 4mg 12) data sheet Nicorette 15mg inhalator 13) Taylor, D; Paton, C; Kapur, S (2015) The Maudsley Prescribing Guidelines in Psychiatry 12 th edition Wiley Blackwell Chichester 14) e-stockley Accessed 15 th June ) data sheet NiQuitin 21mg transdermal patch 14