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Clinician’s Corner: Smoking Cessation Therapies

Last week we discussed the role of nicotine replacement products.  This week we will focus on the role of prescription drugs indicated for smoking cessation.  Your Thompson Pharmacist can help guide you through the challenges of quitting smoking, with these prescription products.

The effect of smoking on drug metabolism:

Hydrocarbons found in tobacco smoke may speed up many drugs that are metabolized by the liver.  When a patient quits smoking, levels of these drugs have the potential to increase: Theophylline (Theo-24), clozapine (Clozaril), olanzapine (Zyprexa), and tizanidine (Zanaflex), caffeine and acetaminophen.

Bupropion-SR 150mg ——-cost $20.00/month

Usual dose 150mg daily for 3 days. Then increase to 150mg twice daily.  Separate doses by 8 hours.

Initiate treatment when patient is still smoking.  Takes 1 week to achieve steady state blood levels.

Set a target quit date within the first 2 weeks of treatment. Continue treatment for 7 to 12 weeks.

After 7 weeks of treatment failure, unlikely patient will succeed. Consider stopping therapy.

May be combined with nicotine patches.  Consider for smokers with history of depression.  This drug is safe for patients with cardiovascular disease.  This drug may be useful in delaying weight gain from smoking cessation.

AVOID: if bipolar, pregnant or history of seizures and patients with significant anxiety

Varenicline  (Chantix®)   cost—-$450.00/month

Mechanism: occupies nicotine receptors in the brain. Having the drug on board blocks some of the pleasurable effects that patients get if they smoke.  Have patients set quit day around day 8, after full titration.

STARTER PACK: Dose: day 1-3: 0.5mg daily

  • Day 4-7: 0.5mg twice daily
  • Day 8-through end of treatment- 1mg twice daily
  • Assess after 12 weeks. If successful start a second 12-week drug course.

Common Adverse effects: Nausea, dream changes, constipation, gas and vomiting.

Prescribe with caution:

  • Avoid: Chantix should NOT be used by pilots, air traffic controllers, truckers, and bus drivers. This recommendation was first made in 2008. Chantix is still on the “Do not issue- Do not fly” list as of February 21, 2019. (source faa.gov)
  • Mental Health effects: Patients should stop taking Chantix and call their health care professionals right away if they notice any side effects on mood, behavior, or thinking. Suggested link to heart attacks, seizures, diabetes, dizziness, and confusion. The black box warning for adverse psychiatric events was removed on December 16,2016
  • Cardiovascular risk: Most sources agree Chantix is save for heart patients, as smoking is a greater risk factor.
  • Kidney disease: dose adjustments should be made. Ask your Thompson Pharmacist

Patient education:

  • Set a quit date. Start Chantix® one week before that. Prescribe the “starter pack.”
  • Take after a meal with a full glass of water to minimize stomach upset.
  • Caution driving until patient sees how the drug affects them.
  • Caution if kidney problems, pregnant or nursing.

Second Line Drugs for Smoking Cessation:

  • Nortriptyline (Pamelor): Similar efficacy to bupropion or nicotine replacement, but safety profile limits its usage.  More side effects.
  • Clonidine (Catapres): helps decrease cravings and agitation from stopping smoking.

Your Thompson Pharmacist’s Role   ALL health care professionals should discuss at EVERY encounter diet, exercise and smoking cessation.  Your Thompson Pharmacist cares about your health and wants you to be successful in quitting smoking.