19 INSTRUCTOR GUIDELINES

Transcription

1 STAGE: Recent Quitter You are a pharmacist in a smoking cessation clinic and you receive a phone call from one of your patients, Ms. Onitay. She is moderately panicked and tells you that she has a swollen red rash on one third of her body. She believes the rash is caused by bupropion (Zyban) or the nicotine inhaler, the only two drugs that she currently is using. She has been on bupropion for 11 days and on the inhaler for 4 days. She has been smoke-free for 4 days. KEY POINTS THIS PATIENT recently quit; currently using the nicotine inhaler and bupropion is experiencing a skin sensitivity reaction wants to use pharmacotherapy (the inhaler) during her quit attempt chooses to discontinue the bupropion is concerned about relapse due to work-related stress THE PHARMACIST evaluates and manages a potential bupropioninduced skin reaction addresses psychosocial and other factors related to quitting recommends changes in the pharmacotherapy regimen counsels the patient on how to treat and monitor the adverse drug reaction arranges follow-up counseling Rev CASE 19 Page 1 of 10

2 Step 1: ASK Not applicable. The patient has called the pharmacist for assistance. Step 2: ADVISE Not applicable. The patient is in the process of quitting. Step 3: ASSESS This patient has already begun her quit attempt. Step 4: ASSIST Evaluate current quit attempt Ms. Onitay, I m concerned about your skin rash. Can you describe its appearance for me? Well, it s bumpy, and my skin is all red and splotchy. It s everywhere all over my chest, my arms, even my face and neck. And when did it first appear? Last night, sometime after dinner. I noticed that my neck and arms were itching. It nearly drove me crazy last night. I ve been having problems sleeping lately, and this rash made things even worse. I tried putting calamine lotion on it, but it didn t help. Have you ever had a rash like this before? Rev CASE 19 Page 2 of 10

3 No. Never! Any recent changes to your daily routine? Maybe a new lotion, cream, shampoo, or perfume? Or any new foods in your diet? No, nothing that I can think of. Just the new medications. And not smoking for the past 4 days! Is the rash getting worse, or is it staying the same? Are you having any breathing problems? It s pretty much the same, although my skin is a bit redder because I ve been scratching. And I think my breathing is fine. OK, I m glad the rash is not progressing. Let s talk a bit about your medications. Tell me how you ve been using the Zyban and the inhaler. Well, I ve been using the medications just like we talked about. I ve been taking the Zyban in the morning for the past 11 days, and I added in the second evening dose about a week ago. For the inhaler, I ve been using about 6 cartridges a day for the past 4 days, ever since I quit smoking. When were your last doses of Zyban and the nicotine inhaler? Rev CASE 19 Page 3 of 10

4 My last dose of Zyban was yesterday evening, about 8:00. And I stopped using the inhaler when I noticed the rash. I was afraid to use either without talking to you first. What do you think is going on? It seems that you re having a drug-induced skin reaction. Of the two drugs, Zyban is more likely to cause a rash, although it s quite uncommon. It occurs in less than 3% of patients. A rash is not a known side effect of the nicotine inhaler. Well, the fact that you ve been taking the Zyban at full dosages for about a week makes me think Zyban is the cause. Zyban takes about a week to reach its therapeutic level, so this probably accounts for the delayed appearance of your rash. Let s take you off of the Zyban. Have you used any other medications, besides calamine lotion, to treat the rash? No. I was afraid to take anything else. Are you allergic to any medications? No. I m not allergic to anything that I know of.well, except maybe to Zyban! Let s put you on an antihistamine to help with the rash and itching. Have you taken antihistamines before? And if so, do they make you sleepy or drowsy? Yes. I ve taken Benadryl, and it knocks me out. I wouldn t mind taking it when I got home after work, but I d rather not take anything like that during the day. Rev CASE 19 Page 4 of 10

5 OK, then let s put you on mg of Benadryl (diphenhydramine) when you get home today and repeat that dose 4 6 hours later, just before bedtime. Also, I d like you to use 1% hydrocortisone cream on the affected areas of skin. This will help with the itching. You can use it 3 4 times a day, but if things don t start clearing up in the next day or two, we should talk again and might need to get you some prescription medication. If the rash is caused by Zyban, the symptoms should start improving in the next few days, although it might take up to a week to get the drug completely out of your system. Discuss key issues: confidence in ability to quit In spite of this setback, how are things going? Well, to be honest, things have been pretty bad. I ve had terrible insomnia for the past week. I can t seem to fall asleep before midnight. Now with this rash, it s even worse. And to top it off, now I m afraid to use the medications. If you want to know the truth, I could really use a cigarette right now. You ve definitely had a more difficult time than planned. The first week is the hardest and to have all of this on top of it! I know you ve been tested these past few days. How have you been holding up? Have you smoked any cigarettes, even a puff? Nope not a one. There have been several times where I ve wanted to smoke badly, but I ve used the inhaler instead. It wasn t the same as a cigarette but it definitely helped. I m so happy you don t think it s the inhaler that s causing the problems! Ms. Onitay, that s great news! This is a major accomplishment, especially considering what you ve been through. I m glad to hear the inhaler is working for you. Are you feeling confident in your ability to remain smoke-free for good? Rev CASE 19 Page 5 of 10

6 Pretty much. I mean, I ve gone 4 days without a cigarette. But I m worried that I can t do this without some sort of crutch. I ve got some major deadlines at work, and I m sure I ll be tempted to fall back into my old ways if I don t have something to help me through this. Discuss key issues: concerns about withdrawal symptoms Tell me about the withdrawal symptoms you ve been having. Well, I just seem to be on edge all the time. Kind of hateful. My fuse is really short, and my mind is constantly wandering. Plus, I ve had trouble sleeping. These are common symptoms. But the good news is that the irritability, poor concentration, and difficulties sleeping are worst during the first 1 2 weeks after quitting, and they gradually lessen and disappear within a month. Using the inhaler regularly should help with the irritability and lack of focus. It s also possible the insomnia was caused by the Zyban that s a common side effect of it. Discuss key issues: stress-related tobacco use You mentioned that you ve got some big deadlines at work. Tell me about any other stressors in your life right now. That s pretty much it right now. I just have to finish up my end-of-quarter reports and deal with this horrible rash. Discuss key issues: social support for quitting Rev CASE 19 Page 6 of 10

7 Tell me about your support system these past few days. My husband, friends, and co-workers have been great. My husband has been especially wonderful, considering how witchy I ve been lately. I m really lucky to have this kind of support. That s great to hear. The effects of nicotine withdrawal should dissipate over the next few weeks, but remind your family and friends that you will need their continued support in the coming weeks and months. And, of course, you can always call us for assistance. We re here to help you. Facilitate quitting process: provide medication counseling So, let s talk about your meds now. We re taking you off the Zyban it s the most likely culprit. The side effects associated with the nicotine inhaler are usually irritation to areas of the body that come into contact with the inhaled vapor, such as the mouth and throat. Considering you didn t get a rash when you were smoking, the active medication in the inhaler nicotine is unlikely to be causing the problem. Are there any other chemicals or additives in the inhaler? Yes, menthol is an inactive flavoring agent added to the cartridge, but you used to smoke menthol cigarettes, right? Yes, that s true. You know, I m relieved to hear the inhaler isn t causing the rash. Rev CASE 19 Page 7 of 10

8 Well, we won t know for certain what is causing your rash until you re no longer exposed to whatever is causing the reaction. Usually when we suspect that a drug causes a reaction, we have patients stop taking the medicines likely to be causing the reaction and see what happens. An ultra-conservative approach would be to stop both the Zyban and the inhaler and observe the rash for several days. But because you feel the inhaler is working well for you, and because the probability that this medication is causing the reaction is so low, I recommend that we stop only the Zyban for now. Of course, if the rash doesn t improve over the next few days, or if it worsens, I want you to stop using the inhaler and call one of us at the clinic. Facilitate quitting process: discuss coping strategies Now, because you ve mentioned you are experiencing some job-related stress, perhaps we should talk about some potential coping strategies to help you in the coming weeks. Well, I ve been doing lots of deep breathing, and that seems to help. But I m worried that I seem to think about cigarettes a lot these days. I m glad you ve found deep breathing to be helpful. Are there any other things you can do to distract yourself when you feel stressed and want to smoke? The pharmacist should have the patient reflect on this and develop her own unique coping strategies. Having the patient devise her own approach is likely to be much more effective. The pharmacist can help the patient to think about plans to change the way she thinks (cognitive strategies) and the things she does (behavioral strategies) in response to temptations to smoke. Rev CASE 19 Page 8 of 10

9 If the patient can t think of coping strategies, the pharmacist could suggest the following: Behavioral Coping Strategies: Move on to a different task. Take a break (go for a walk outside, read a book, surf the Web, work on a crossword puzzle). Call a supportive friend or family member. Cognitive Coping Strategies: Remember that thinking about a cigarette does not mean you have to smoke one. On a daily basis you think about things you wouldn t actually do. Don t dwell on your thoughts about cigarettes. Just say to yourself, I want a cigarette. So what? I also want to win the lottery and live in a mansion. Big deal. Then move on to something else. Don t worry about your thoughts about cigarettes. This is normal in the early stages of quitting. Just recognize this and move on. Step 5: ARRANGE Ms. Onitay, let me congratulate you again on remaining smoke-free these past 4 days. You ve gone through a lot recently and have made significant progress. You should be very proud of yourself! As we discussed, I d like you to stop taking the Zyban and treat the rash with an antihistamine and hydrocortisone cream. I d also like you to continue using the nicotine inhaler at least 6 cartridges per day. It will help with the withdrawal symptoms. Remember, this is not a crutch. It s a medication to treat your dependence and help you stay smoke-free. Does this plan sound reasonable? Yes, very much so. Rev CASE 19 Page 9 of 10

10 Step 5: ARRANGE (cont d) I d like us to keep in close contact over the next few days, to monitor your drug reaction. If you don t mind, I d like to call you on a daily basis to discuss how things are going with the rash and provide a little extra support during this point in your treatment. Of course, if the rash worsens, please call us immediately. Is this OK with you? Yes, of course. I really appreciate it. It s not a problem. I m incredibly pleased with how well you re doing. I wish all my patients were this dedicated when they quit. One final thing, with your permission, I d like to report this incident to MedWatch, the Food and Drug Administration safety information and adverse event reporting program. It s important that we report this incident so the agency can update health care professionals and consumers on the real-life frequency of drug-related adverse effects. Sure, that s OK with me. Thanks again for your help, and I ll talk to you tomorrow. Rev CASE 19 Page 10 of 10