Transcript MPA Advocacy Group

NICOTINE
REPLACEMENT
THERAPY
NRT
Dr. Debbie Thompson; Dr. Jane Dumontet
Clinical Pharmacy Specialists for Fraser Health
Feb 2008
Objectives
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Understand the difference between cessation
and withdrawal
Review the various Nicotine Replacement
Therapy options
Contrast the symptoms of nicotine toxicity
versus those of withdrawal, psychiatric
symptoms, caffeine side effects
Nicotine Withdrawal
Patients without access to cigarettes abruptly due
to non-smoking policies will experience
withdrawal symptoms
Initial Goal/Priority
to make patients as comfortable as possible by
preventing withdrawal symptoms
 Thank-you for not smoking here!
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Secondary Goal  Cessation
Physiological Considerations
Withdrawal
Nonspecific symptoms
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Vary in intensity and duration
Begin within hours
Peak in 2 to 3 days
Last weeks to months
Symptoms
 Irritability, frustration or
anger
 Anxiety, restlessness
 Dysphoria or depressed
mood
 Difficulty concentrating
 Increased appetite or weight
gain
 Insomnia
 Decreased heart rate
Nicotine Withdrawal
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Immediate
 Nicotine Replacement Therapy
 Gum, Lozenge, (Inhaler)
 Patch
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Delayed
 Bupropion
 Varenicline
Keep Nicotine Levels Close to
Comfort Zone
http://www.esr.cri.nz/competencies/populationhealth/NRT.htm
Nicotine Levels/24 Hours
Continuous Smoking
http://images2.clinicaltools.com/images/tobaccofree/nicotine_levels.gif
Nicotine Levels/120 Minutes
Single Dose
Nicotine

Cigarettes contain 6 to 11 mg of nicotine
Smokers absorb between 1 to 3mg from each
cigarette i.e. average 2mg
 If a pack contains 20 cigarettes
 20 cigarettes x average 2mg each = 40mg/day

(1 PACK = 1 x 21 mg PATCH)
1 Habitrol 21 patch is designed to provide 21 mg over
24 hours of which only about 76% reaches the
bloodstream i.e. about 16mg
High Risk Smokers - Mentally Ill
More likely to smoke longer, be heavy users, smoke
high tar brands with high nicotine contents
 And smoke that cigarette to the bitter end
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So likely getting more than 2mg out of each cigarette
Psych Services 1999. 50:1346-50
NRT FH Protocol
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Nicotine patch
7 mg patch - low nicotine dependence
 14mg patch - moderate nicotine dependence
 21mg patch - high nicotine dependence
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+ for moderate or high nicotine dependence
Nicotine 2 or 4 mg gum or lozenge prn to a
maximum of 8/10 pieces respectively /24 hours
DETAILED FAGERSTRŐM ASSESSMENT
1. How soon after waking do you have your first cigarette? Within 5
minutes (3 points)
 6- 30 mins
(2 points)  31- 60 mins
(1 point)
 More than 1 hour (0 points)
2. Do you find it difficult to refrain from smoking in places where it is
forbidden? Yes (1 point) No
(0 points)
3. Which cigarette would you be most unwilling to give up? First in
morning
(1 point)  Any others (0 points)
4. How many cigarettes, on average do you smoke per day? 31 or more
(3 points)
 21-30 (2 points)  11-20
(1 point)
 10 or less
(0 points)
5. Do you smoke more frequently during the first hours after waking than
during the rest of the day? Yes (1 point) No
(0 points)
6. Do you smoke even if you are so ill that you are in bed most of the
day? Yes
(1 point) No (0 points)
7. Assign Score:
SCORE = _________7-10 points = high nicotine
dependence
4-6 points = moderate nicotine dependence
0-3 points = low nicotine dependence
8. Ask the patient if they feel they need assistance with smoking
abstinence in hospital (may not be needed if low nicotine
dependence). Yes  No
Ottawa Heart Protocol
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> 20 cigarettes/day = 21mg patch
10-20 cigarettes/day = 14mg patch
< 10 cigarettes/day = 7mg patch
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+ prn gum or inhaler
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Monitor for withdrawal symptoms
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Within first day to see how they are doing, particularly
if very heavy smoker
May have to increase dose of patch – doctor’s order
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Increase by 7mg at a time and reassess
Encourage use of prn gum, lozenge if not using and
having cravings/withdrawal symptoms
If smoking while on NRT it is likely the dose is likely
not high enough!
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(or if behaviourally they have absolutely no intention of
quitting and are accessing cigarrettes every chance they get –
the patch may not be the withdrawal method of choice)
Nicotine Transdermal Patch
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Well absorbed through
the skin
Onset 1-2 hours
Peak
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Habitrol® 5 to 6 hours
Nicoderm® 4 hours
Peak concentration: 6-12
hrs
Plateau: 8-10 hrs
http://www.quitsmoking.com/books/knowsmoking/chapter5.htm
http://learn.genetics.utah.edu/units/addiction/drugs/delivery.cfm
Nicotine Transdermal Patch
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Plasma levels fall 1-2 hours after removing patch
Duration of therapy
Habitrol – Taper dose by 7mg Q3-4 weeks
 Nicoderm – 6,2,2
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Arbitrary stop date
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NRT is much preferable and safer than continued
smoking
Nicotine Transdermal Patch
(Nicoderm®, Nicotrol®, Habitrol®, Generics)
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Advantages
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Easy to use
Unobtrusive
Provides steady nicotine
levels
Avoids gum side effects
Non-prescription
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Disadvantages
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Cannot adjust dose for
cravings
Nicotine released more
slowly than other
products
Side effects
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Mild skin irritation or
sensitivity
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Important to rotate sites
Switch brands as needed
Insomnia reported
Patch – choice of location
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Choose an area on skin on upper body or the upper outer part of
arm. (UPPER & OUTER)
To ensure that the patch will stick on well, make sure the skin is nonhairy, clean (not oily) dry and free of creams, lotions, oils or powder.
Hair will interfere with the application of the patch and should
be clipped away.
Do not shave the area as this may irritate the skin.
Do not put a patch on skin that is inflamed, burned, has broken out,
or is irritated in any way, because these conditions may alter the
amount of drug absorbed.
Women should not apply the patch to their breasts.
Be sure to apply the patch to a different area each day. The same
area should not be used again for at least one week
Patch application
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Using scissors, carefully cut open the pouch along the edge.
Remove any old patches from skin, fold in half with the sticky
side inward and dispose of properly in the garbage.
Remove the square shiny protective liner from the adhesive side
of the patch.
Immediately apply the sticky side of the patch to the skin and
firmly press it on with the palm of your hand for 10 to 20
seconds.
Make sure that it is sticking well, especially around the edges.
It helps to clean that area of skin with alcohol wipe before
application.
Medical adhesive tape may be used to help keep the patch on.
Wash hands with water only.
The patch should be worn for about 24 hours and be replaced
everyday at about the same time.
Patch Tips
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If insomnia or bad dreams occur
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Take patch off at night or if on multiple patches, consider
taking off one
Nicotine levels will drop overnight so encourage use first
thing of gum or lozenge until patch kicks in
Consider same procedure as with other patches i.e. extra
line on MAR to indicate site and to document removal
More nicotine will be released if exercising heavily so suggest
removal prior to exercise
If smoking – likely dose not high enough, if persistent in not
choosing to quit (i.e. psychotic) and continuing to smoke
perhaps patch not best choice
Nicotine Gum/Nicotine Lozenge
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Buccal absorption, slower
 20 to 30 minutes of
chewing releases 50 to
90% of nicotine
Peak plasma concentrations
 15 to 30 minutes after
starting chewing
Lozenges deliver 25 to 27%
more nicotine than gum
http://www.quitsmoking.com/books/knowsmoking/chapter5.htm
http://www.ennispharmacy.com/smokers.html
Nicotine Gum (Nicorette®)
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Advantages
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User controls dose
Oral substitute
Non-prescription
Sugar free
Delays weight gain
Side effects
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Gastrointestinal
Oral disturbances
Jaw discomfort
Hiccoughs
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Disadvantages
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Proper chewing technique
required
Cannot eat or drink while
chewing gum
Can damage dental work
Difficult for denture
wearers to use
How to use the gum
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Place one piece of gum in mouth and chew very slowly once or
twice.
Stop chewing and "Park it" between your cheek and gums, and
leave it there.
Wait a minute, and then repeat, "Parking" it again on the
opposite side of your mouth. BITE, BITE, PARK. BITE,
BITE, PARK.
You may notice a peppery taste, or a slight tingling in your
mouth – this is nicotine being released and absorbed.
Do not chew continuously or too quickly like ordinary chewing
gum. Doing so may result in light-headedness, nausea, hiccups
or stomach upset because you are swallowing the nicotine
After about 30 minutes, all the nicotine will be released.
Discard the gum in the garbage.
Gum Tips
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Slow down if you start feeling uncomfortable
Do not chew more than one piece of gum at a time
Do not use more than 20 pieces per day.
Avoid drinking acidic beverages such as coffee,
tea, pop, alcohol or citrus fruit juices before or
during use of gum. Doing so may affect nicotine
absorption.
Consult your dentist or doctor if injury or irritation to
the mouth, teeth or dental work occurs.
Accidentally swallowing a piece of gum shouldn't harm
an adult.
Nicotine lozenge
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Place one lozenge in mouth and allow it to dissolve
slowly
Do not chew or swallow – the lozenge contains a
controlled amount of nicotine, which needs to be
absorbed slowly and gradually through the tissues in the
mouth
A tingling, or warm sensation may occur
Occasionally move the lozenge from one side of the
mouth to the other
It takes about 20-30 minutes for the lozenge to dissolve
completely
Lozenge Tips
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Do not eat or drink 15 minutes before using, or
while the lozenge is in your mouth
Do not use more than one lozenge at a time or
continuously use one lozenge after another.
Doing so may cause hiccups, heartburn, nausea
or other side effects.
Do not use more than five lozenges in six hours,
or more than 15 lozenges total per day.
NRT Side Effects
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Relatively few side effects
Minor side effects mild headache, appetite
stimulation, constipation, diarrhea, dizziness,
dysmenorrhea, flushing, insomnia irritability
 Others include hiccups, jaw ache, sore throat
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Of Note!
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Remember – there is a lot of nicotine left in a
patch (a Habitrol patch that releases 21 mg
actually contains 51 mg total)
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A 21 mg patch of Nicoderm has 114mg total
2 mg of a 4mg piece of gum
4mg of a 10mg inhaler cartridge
DISPOSE OF SAFELY IN GARBAGE
Very toxic to nicotine naïve – children, animals
 WARN parents that this is not innocuous
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Supply and Charting
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Ensure ready access to gum and patch on ward
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Consider initial wardstock supply of both
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If large anticipated # patients on a ward, consider
wardstock for prn versus patient specific
Consider providing a few gum or lozenges at a time
depending upon the compliance and understanding
of the patient
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How will this be charted?
Access to the inhaler?
 Patients with patch allergy?
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Considerations
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Withdrawal versus toxicity
Depression
Drug interactions with smoking cessation and
resumption
Cardiac risks
Discharge planning
Withdrawal vs. NRT Excess
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Nicotine Intoxication:
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Pallor, diaphoresis
Tremor, headache, dizziness
 Confusion
 Tachycardia, Palpitations
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 N/V/D,
abdominal pain
 Hypersalivation
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Treatment????
Withdrawal vs. Caffeine toxicity
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Sudden cessation of tobacco smoking may result in
reduced caffeine clearance (~ 40%)
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Caffeine-related side effects may occur if use remains
the same or increase if drink more coffee for
something to occupy them
 Nausea,
nervousness, irritability, tremors,
insomnia
Differentiate between withdrawal symptoms of
smoking cessation and excess caffeine!
Withdrawal vs. Psychiatry Symptoms
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Very important to differentiate as many
symptoms overlap
Anxiety
 Restlessness
 Irritability
 Mood changes
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Depression
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Current and past depression more common in
smokers
Experience more depressive symptoms during
withdrawal
 Increased risk of recurrent depression after stopping
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JAMA 1990. 264:1546-9
Smoking Cessation and Drug
Interactions
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Hydrocarbons in tobacco induce drugmetabolizing enzymes (not the nicotine)
particularly CYP 1A2
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Can take several weeks to get to maximum inhibition
as well as to return to baseline following
discontinuation
Pharmacotherapy, 1998;18(1):84-112, Psychiatric times, 2005;22(6)
Psychiatric Medications Affected
Extent of interaction highly variable
Examples include;
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Caffeine
Antidepressants
 Imipramine, clomipramine, fluvoxamine, trazodone
 Variable effect on Amitriptyline and Nortriptyline
Antipsychotics
 Fluphenazine, haloperidol, olanzapine, chlorpromazine,
clozapine
Benzodiazepines
 Alprazolam, lorazepam, oxazepam, diazepam
Desai HD et al. CNS Drugs 2001. 15(6):469-94
Clozapine and Olanzapine
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Individual cases of large increases in serum
levels with smoking cessation
Consider baseline serum levels particularly of
clozapine
Monitor for increased adverse effects for the
first few weeks after smoking cessation
i.e. Sedation, increased drooling, dizziness
Nicotine, Smoking and Diabetes
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Tobacco smoking is known to aggravate insulin
resistance; Insulin absorption is slowed from injection
sites.
Cessation of NRT or tobacco smoking may decrease
blood glucose
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Stopping smoking will increase subcutaneous absorption of
insulin
Recommend monitoring blood glucose concentrations when
nicotine intake or smoking status changes
Dosage adjustments in antidiabetic agents may be required
Nicotine CV risk
The use of NRT is not associated with any increase in
the risk of MI, stroke or death
(N = 33,247 Hubbard 2005)
 Much more rapid absorption of nicotine when smoking
 Smoking produces higher nicotine peaks than
NRT
 Any patient who is at risk of smoking is safer on
NRT than continuing to smoke
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http://www/quitsmoking.com/books/knowsmoking/chapter6.htm
At Discharge
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If an individual resumes smoking at discharge
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Levels of medication (particularly clozapine and olanzapine)
are likely to fall potentially resulting in relapse
Plan
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Baseline serum levels of clozapine, (olanzapine)
Provide information to discharge treatment team of smoking
status
Provide education/information to patient of potential impact
of changes in smoking habits and that they should inform
their treatment team if they resume or quit smoking
PATCH
Go Green
Use Clean Nicotine
GUM
LOZENGES