Comparison Of Current Pharmacotherapy For Nicotine Dependence Treatment** Rx Bupropion HCI
Pharmacotherapy Guide OTC Nicotine Patch
OTC Nicotine Gum and Lozenge
Rx Nicotine Spray
Rx Nicotine Inhaler
SR Tablet
NICORETTE® (gum) COMMIT® (lozenge) NICOTROL® INHALER 24 mg, 14 mg, 7 mg 0.5 mg, 1 mg tablets 150 mg/day (days 1–3) .05 mg/day (days 1–3) 1 piece of gum/lozenge every 1–2 hours 1–2 doses/hour (1 dose = 2 sprays per nostril) 6–16 cartridges/day 300 mg/day (days 4+) .05 mg/2x/day (days 4–7) 1.0 mg/2x/day (days 8+) MAX DOSING
24 piece of gum/24 hours 20 lozenges/24 hours 5 doses/hour or 40 doses/day 16 cartridges/day TIME TO PEAK PLASMA LEVEL
Initiate 1 week before quit date.
Continue up to 12 weeks.
7–12 weeks after quit date For those quit at 12 weeks, taper during final 3 months another 12 week course may be recommended Nausea, sleep disturbance, 50% experience mild skin reactions (rotate and use 40% experience mouth and throat Dry mouth; insomnia Mouth soreness, hiccups, dyspepsia and, for gum, Local transient irritation in the nose and throat, constipation, flatulence, and steroid cream); vivid dreams, sleep disturbances irritation (resolved through regular use); (avoid bedtime dose); jaw ache (usually mild and transient; correct technique watery eyes, sneezing and cough, runny nose vomiting. Do not use with while on the patch for 24 hours (remove at bed time) shakiness and skin rash NRT: increases adverse effects.
In patients on renal dialysis or severe renal insufficiency Seizure disorder; current use (GFR<30ml/mn), must reduce Severe TMJ disease or other jaw problems; of Wellbutrin/bupropion; current dose to 0.5mg daily. All patients Severe eczema or other skin diseases which may be presence of dentures or Mouth or throat irritation or prior dx of bulimia or anorexia Asthma, rhinitis, nasal polyps, or sinusitis Allergy to menthol should be observed for exacerbated by the patch; allergy to adhesive tape other dental appliances; from any other cause nervosa; concurrent or recent (GENERAL NRT CONTRAINDICATIONS ON OTHER SIDE)
mouth or throat irritation use of MAO inhibitors; including changes in behavior, from any other cause bupropion allergy agitation, depressed mood, suicidal ideation, and suicidal behavior.
$5.20–$6.20/12 pieces 6.50–$7.50/12 lozenges $5.50 for 12 doses $8.00 for 6 cartridges (PRICES AS OF 4/00)
WHY SHOULD YOU RECOMMEND Choice And Use Of Pharmacotherapy Peptic Ulcer Disease
Combination Therapy  Recommended duration of therapy is up to 12 wks.
 Nicotine may delay healing of active ulcers.
There is limited evidence that combining patch and other NRTs or OR PRESCRIBE PHARMACOTHERAPY patch and bupropion may slightly increase quit rates over monotherapy.
 No studies are available on the effects of NRT on ulcer disease.
May be the best choice of NRT for most patients. Adherence NICOTINE NASAL SPRAY Combination therapy may be considered in persons who have failed FOR YOUR PATIENTS WHO SMOKE? is usually better than with nicotine gum, spray or inhaler.
Nicotine nasal spray is available by prescription only. It provides the  Weigh risks and benefits of NRT in patients with active ulcer.
on monotherapy or are heavily addicted.
Dose & Technique:
most rapid nicotine delivery of all NRT products and provides greater Other Conditions Which May Contraindicate NRT
Note Regarding Psychiatric Conditions  Start most smokers of 10–15 cigarettes or more/day at the highest
capacity for self-titration of dose. Dependency potential is greater with  Severe renal failure.
Although psychiatric conditions (e.g., depression, alcohol abuse and Because there is strong evidence that the spray than with nicotine gum or the nicotine patch.
 Active hyperthyroidism.
dependence) place smokers at increased risk for relapse to smoking,  If vivid dreams or sleep disturbances are experienced, remove
Dose & Technique:
pharmacotherapies are effective for a  Poorly controlled insulin-dependent diabetes.
smoking cessation treatments can be effective, and NRT and bupropion  Usual single dose is two sprays, one in each nostril.
 Severely uncontrolled hypertension.
should be considered as part of a comprehensive approach to cessation.
broad range of smokers. Use of NRT  Consider lower starting doses in smokers of less than 10 cigarettes/day.
 Start patient at 1–2 doses/hour.
 Peripheral vascular disease.
One of the benefits of NRT and bupropion is that they abate mood- and/or bupropion approximately doubles  A new patch is applied each morning to the upper torso.
 Maximum dose: 5 doses/hour or 40 doses/day.
related withdrawal symptoms but produce relatively few adverse effects.
Children & Adolescents
long-term quit rates.
NRT should be considered in children and adolescents only when  Treatment of 8 wks or less has been shown to be as effective as longer
 Recommended duration of therapy is 3–6 months.
there is clear evidence of nicotine dependence and clear desire to quit.
Dose & Technique:
Degree of dependence and body weight should be considered when  Maximum dose is 2.0 mg/day, given as 1.0 mg twice daily.
 Tapering dose after 4 wks is generally recommended for most smokers.
WHICH OF YOUR PATIENTS The nicotine inhaler is available by prescription only. It addresses selecting NRT dose.
 Dosing should begin at 0.5 mg/day given every day for the first 3 days,
 Use for longer duration if unsuccessful on shorter duration.
pharmacological, behavioral and sensory stimuli aspects of smoking.
Pharmacotherapy & Pregnancy followed by a dose increase to 0.5 mg taken morning and evening SHOULD USE PHARMACOTHERAPY?  Use for longer duration at higher dose for heavier smokers.
The nicotine is absorbed through the lining of the mouth.
There are no adequate studies on the safety of pharmacotherapy in for the next 4 days. On Day 8 and beyond, the recommended dose is Dose & Technique:
pregnant women. Pregnant smokers should be encouraged to quit using 1.0 mg b.i.d.
NICOTINE GUM or NICOTINE LOZENGE behavioral interventions before pharmacological approaches are used.
 A dose consists of a puff or inhalation.
May be a good choice for patients who:  Treatment with varenicline should be initiated while the patient
Pharmacotherapy is recommended only if the increased likelihood of  Each cartridge delivers 4 mg of nicotine over 80 inhalations; only 2 mg
is still smoking; approximately one week of treatment is required  Have not been successful on the patch.
to ALL patients who smoke AND: smoking cessation clearly outweighs the risk of pharmacotherapy.
are actually absorbed (this is the equivalent of about 2 cigarettes).
to achieve steady- state blood levels. Quit attempt should occur  Prefer the gum or lozenge for personal reasons
 Advise patient not to drink acidic beverages 15 min before and during
during second week of treatment. Patients should be encouraged  Are interested in quitting AND
 Have had a severe skin reaction to the patch.
the inhalation.
May be a good choice for patients who: to continue to attempt to quit if they have early lapses after quit day.
 Do not have a medical contraindication
Dose & Technique:
 Best effects are achieved by frequent puffing.
 Do not have a history of seizures.
 Specify 2 mg gum for those who smoke less than 25 cigarettes/day.
 Recommended dosage is 6–16 cartridges/day; patients may self-titrate
 Prefer an alternative to nicotine replacement.
 Treatment should be continued for up to 11 weeks following quit date.
to NRT or bupropion (see Precautions / Specify 4 mg gum for more highly dependent smokers (25 or more to the level of nicotine they require.
Dose & Technique:
 Patients who are abstinent at week 12 may benefit from and additional
cigarettes/day, smoking within 30 min of awakening, and/or those  Maximum dose: 16 cartridges/day.
 Maximum dose is 300 mg/day, given as 150 mg twice daily.
course of 2.0 mg b.i.d. for up to twelve weeks.
finding it difficult to refrain from smoking where it is forbidden).
 Dosing should begin at 150 mg/day given every day for the first 3 days,
 Dose tapering is not required when discontinuing treatment.
 Specify 2 mg lozenge for those whose first cigarette of the day is more
** Little research is available on the use of pharmacotherapy with patients who smoke less than
followed by a dose increase for most patients to the recommended dose 10 –15 cigarettes per day. For these light smokers a lower starting dose of the nicotine patch than 30 min after awakening. Specify 4 mg lozenge for those who  Recommended duration of therapy is up to 6 months.
Combination Therapy of 300 mg/day. Interval of at least 8 hours between successive doses.
or gum could be considered. No adjustments are necessary when using bupropion SR.
smoke within 30 min after awakening.
 Instruct patient to taper dosage during last 6–12 wks of treatment.
Varenicline should not be used in combination with NRT due to  Treatment with bupropion should be initiated while the patient
** Inclusion of this adult dosage chart is strictly for the convenience of the prescribing provider.
 Recommend patient use one piece of gum or one lozenge every
increases in adverse affects.
Please consult the Physicians' Desk Reference for complete product information and con- Precautions & Contraindication for all NRT Products is still smoking; approximately one week of treatment is required 1–2 hrs (many patients use less than is needed for optimum effect).
traindications. This chart does not indicate or authorize insurance benefit coverage for any of (See table on back for unique product contraindications and bupropion to achieve steady- state blood levels. "Quit attempt should occur Note Regarding Psychiatric Conditions these medications. For insurance benefit information, the patient will need to contact his/her  Maximum dose: 24 pieces/day of either the 2 mg or 4 mg gum or
during second week of treatment." Serious neuropsychiatric symptoms have occurred in patients being insurer directly. The cost or provision of these medications is not included as any part of the 20 lozenges/day of either the 2 mg or 4 mg lozenge.
Try-To-STOP TOBACCO Resource Center of Rhode Island or QuitWorks program.
treated with CHANTIX. Some cases may have been complicated by Bupropion SR can be used in combination with NRT.
 Proper use is critical to effectiveness. For gum, emphasize the
Although not an independent risk factor for acute myocardial events, the symptoms of nicotine withdrawal in patients who stopped smoking; importance of alternating chewing and parking each piece for 30 min.
NRT should be used only after consideration of risks and benefits among however, some of these symptoms have occurred in patients who con- The Public Health Service issued an updated clinical practice guideline, "Treating Tobacco Use and For lozenge, patient should allow it to dissolve slowly, occasionally  Treatment should be continued for 7–12 weeks following quit date.
particular cardiovascular patient groups including: tinued to smoke. All patients being treated with CHANTIX should be Dependence," in June 2000. This brochure summarizes the PHS recommendations and provides moving it from one side of the mouth to another.
 Patients who have not made significant progress towards abstinence
information on the appropriate use of nicotine replacement therapy (NRT) and bupropion SR (Zyban®).
 Those in immediate (within 4 weeks) postmyocardial infarction period.
observed for neuropsychiatric symptoms including changes in behavior, QuitWorks was developed by the Massachusetts Department of Public Health (MDPH) in collabora-  Advise patient not to consume acidic beverages or food 15 min before
by the seventh week of therapy are unlikely to successfully quit during agitation, depressed mood, suicidal ideation and suicidal behavior.
 Those with serious arrhythmias.
tion with Massachusetts health plans and has been in operation since 2002. The program has been and during gum and lozenge use.
this attempt and treatment should be discontinued.
adopted by the Rhode Island Department of Health with permission of the Massachusetts Department  Those with severe or worsening angina pectoris.
Precautions & Contraindication for all NRT Products  For maintenance therapy, consider 150 mg b.i.d. for up to 6 months.
of Public Health. The Pharmacotherapy Guide was developed by the Center for Tobacco Prevention and (See table on back for unique product contraindications and bupropion Control, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School.
 Dose tapering is not required when discontinuing treatment.
Updated in 2008.



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