Smoking Cessation Pharmacotherapy Options

Nicotine Replacement Therapy (NRT)

• Combination NRT: preferred d/t effectiveness, combines nicotine patch with a short acting NRT (gum or lozenge)
• Can combine Chantix with nicotine patch 

Nicotine patches 

• Provides sustained withdrawal symptoms relief for 24 hours 
• Start on the quit date, dosing based on smoking intensity, tapering is optional 
• Patient smoking >10 cigarettes/day
  • Begin with step 1 (21 mg/d) for 6 weeks followed by 
  • Step 2 (14 mg/d) for 2 weeks 
  • Finish with step 3 (7 mg/d) for 2 weeks 
• Patients smoking <10 cigarettes/day 
  • Begin with step 2 (14mg/d) for 6 weeks 
  • followed by step 3 (7 mg/d) for 2 weeks 
• Side effects: generally well tolerated but high doses can cause rapid HRT, dizziness, HA, nausea. More commonly causes skin irritation or insomnia/vivid dreams (consider removing patch at bedtime). 
• Use in caution in pts with angina, HTN, recent MI, esophagitis, active gastric or peptic ulcer disease, and renal/hepatic impairment 

Short acting NRT Options

• Nicotine gum or lozenges: one every 1-2 hours while awake and also whenever there is an urge to smoke 
  • if smoke within 30 min of awakening: 4mg dose
  • if smoke after 30 ming of awakening: 2mg dose 
• Side effects: most irritation, N/V, abdominal pain pain, constipation, ulcers, HA

Nicotine Nasal Spray

• prescription required 
• rapid nicotine delivery mimicking smoking 
• Dose: 1-2 sprays/hour. Max dose 10 sprays/hour, do not exceed 80 total sprays/day 
• side effects: nasal irritation 

Varenicline (Chantix)

• reduces cravings and makes smoking less pleasurable d/t blocking nicotine receptors 
• considered safe but monitor for side effects 
• Start 1 week prior to start date 
• Initial dose (starter pack): 0.5mg once daily for 3 days then 0.5mg BID for the next 4 days 
• Increase to 1 mg BID day 2-12 weeks 
• if successful, consider continuing for another 12 weeks 
• side effects: nausea, sleep disturbance (insomnia, vivid/unusual dreams)

Bupropion Sustained Release (Wellbutrin SR)

• clinically less effective than Chantix or combination NRT but still an option
• good option if someone is worried about weight gain with smoking cessation or if they also have depression 
• Dosing: use 12 hour SR no the extended release (XL) form 
  • start 1 week before quit date 
  • start 150mg PO daily for the first 3 days 
  • if well tolerated, increase to 150mg BID 
• contradiction: H/o seizures 

Follow up: 1-2 weeks after quit date, then 3 months and 1 year

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