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137 Cards in this Set
- Front
- Back
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% want to quit smoking
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70%
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% adults that are current smokers
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20.8%
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highest prevelance of adult smoking
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american indian/alaskan native
GED diploma |
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tobacco smoke
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4,800 compounds
11 proven carcinogens |
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carcingoenic gases in tobacco smoke
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carbon monoxide
hydrogen cyanide ammonia benzene formaldehyde |
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carcinogenic particles in tobacco smoke
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nicotine
nitrosamines lead cadmium polonium-210 |
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smoking attriubted death greatest % is
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cardiovascular dx followed by lung cancer than respiratory dx, then 2nd hand smoke
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societal costs of ciggarette smoking
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$7.18/pack
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smokeless tobac loss
can cause |
gingival recession
bone attachment loss dental caries oral leukplakia oral cancer pharyngeal cancer |
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2nd hand smoke affects children by
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increased risk of SIDS
acute respiratory infections ear problems more severe asthma respiratory symptoms slowwed lung growth |
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2nd hand smoke effects on adults
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AEs on cardiovascular system
increased risk for cornoary heart dx and cancer |
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quit smoking in 2wk - 3 months
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circulation improves
walking becomes easier lung function increases by 30% |
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quit smoking in 1-9 months
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lung cilia regain normal function
clear lungs of mucus coughing, fatigue, & SOB decrease |
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quit smoking in 1 year
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risk of CHD decreased by 50% than that of a continued smoker
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quit smoking in 5 years
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risk of stroke is reduced to that of a nonsmoker
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quit smoking in 10 years
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lung cancer death rate drops to half that of a continued smoker
risk of cancer decreases |
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quit smoking in 15 years
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risk of CHD is similar to nonsmokers
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nicotine
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pyridine and pyrrolidine ring
nicotiana tabacum natural liquid alkaloid colorless, volatile base pka = 8.0 |
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nicotine absorption
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well absorbed across membranes in alkaline medias
31% is abosrbed at pH7.3-7.5 (readily absorbed) |
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significant absorption of nictoine in alkaline media like
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pipes
cigars spit tobacco PO nicotine products |
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nicotine absorption
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aborbed in skin, small intestine, and lungs (1 mg of nicotine absorbed/cigg)
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nicotine metabolism
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low bioavailability: 20-45% due to 1st pass heptic metabolism
10-20% excreted unchanged in urine and breast milk 70-80% cotinine metabolite |
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nicotine t1/2
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2 hours
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cotinine t1/2
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16 hours
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nicotine effects
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stimulatory
pleasure,arousal,improved task performance, anxiety relief, appetitie suppression, increased metabolism, increased HR, CO, BP, vasoconstriction |
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nicotine results in release of dopamine
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pleadure
appepitte suppression |
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nicotine results in release of Ne
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arousal
apettite suppression |
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nicotine results in release of Ach
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arousal
cognitive enhancement |
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nictoine results in release of glutamate
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learning
memory enhancement |
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nictorine results in serotonin release
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mood modulation
appepitite suppression |
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nicotine results in release of beta-endorphin
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reduction of anxiety and tension
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nicotine results in release of GABA
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reduction of anxiety and tension
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nicotine withdrawal symptoms
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start @ 1-2 days
peak in a wk subside in 2-4 wks |
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score > 5 on Fagerstrom Test
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substantial dependence
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smoking DIs due to induction of CYP1A2 (decreased effectiveness)
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bendamustine
caffeine clozapine Erlotnib Fluvoxamine olanzapine rpinrole tacrine theophylline irnotecan (due to increased glucorunidation) |
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QuitKey
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nonpharmacologic computer developed taper based on patient's smoking level
includes telephone couseling |
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smoking + OCPs
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does not decrease efficacy of OCPs
increased risk of stroke, MI, and thromboembolism |
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drugs for smoking cessastion
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NRT (gum. losenge, ihaler, nasal spray, patch)
psychotropics (bupropion SR) partial nicotinic receptor agonist (varenicline) |
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Category C
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varencline
bupropion SR |
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category D
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Rx NRT
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No NRT for
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smokeless tobacco users
smoke <10 ciggs/day </=18 years old (need Rx) |
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Nicorette OTC
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polacrilex gum OTC
generic OTC |
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Nicotrol NS
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nasal spray Rx
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commit
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lozenge OTC
generic |
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nicotrol
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inhaler Rx
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NicoDerm CQ
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trandermal patch OTC
generic OTC & Rx |
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NRT
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when start stop all tobacco use
doubles quit rates precuations in underlying CV dx recent MI in past 2 wks serious arrhythmias serious or worsening anginas only if under MD supervision |
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nicotine gum
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resin complex (nicotine & polacrilin)
sugar free buffering agents enhance buccal absorption 2mg/4mg |
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4 mg nicotine gum
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>/=25 ciggs/day
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2mg nicotine gum
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<25 ciggs/day
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Nicotine Gum dosing
wk 1-6 |
1 piece Q1-2 hours
use at least 9 pieces/day no more than 24/day |
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nicotine gum dosing
wk7-9 |
1 piece Q 2-4 hours
use at least 9 pieces/day no more than 24/day |
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nicotine gum dosing
wk 10-12 |
1 piece Q4-8 hours
use at least 9 pieces/day no more than 24/day |
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effectiveness of nicotine gum reduced by
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acidic drinks (coffee/juices/wine/soda)
do not eat/drink 15 minutes before chew gum |
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chew gum too rapidly
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excessive release of nicotine
light headed N/V irriation of throat/mouth/stomache |
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nicotine gum AEs
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mouth soreness
hiccups dyspepsia jaw muscle ache stick to dental work |
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nicotine gum pros
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satisfy oral craving
4mg delay weight gain titrate tx to manage symptoms flavors |
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nicotine gum cons
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need frequent dosing
stick to dental work chew & park not socially acceptable |
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nicotine lozenge
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polacrilex formulation
delivers 25% more nictoine than gum! sugar free buffering agents to enhance nicotine absorption 2mg/4mg |
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nicotine lozenge dosing based on
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time to 1st cigg in morning
> 30 minutes use 2mg < 30 minutes use 4 mg |
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nictoine lozenge dosing
wk 1-6 |
1 lozenge Q1-2 hours
use at least 9/day during 1st 6 wks </=20 lozenges/day |
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nicotine lozenge dosing
wk7-9 |
1 lozenge Q2-4 hours
</= 20 lozenges/day |
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nicotine lozenge dosing
wk10-12 |
1 lozenge Q4-8 hours
</= 20 lozenges/day |
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reduced nicotine lozenge effectiveness with
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acidic beverages (wine/coffee/juices/soda)
do not eat/drink within 15 minutes |
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nicotine lozenge AEs
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nausea
hiccups cough heartburn HD flatulence insomnia |
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nicotine lozenge pro
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satisfy oral cravings
4mg delay weight gain easy to use and conceal titrate therapy to manage symptoms flavors |
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nicotine lozenge cons
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frequent dosing
GI AEs |
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Nicotine patch
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nicotine enters systemic circulation via hepatic 1st pass metabolism
plasma nicotine levels are lower and fluctuate less than smoking |
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Nicotine patch
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NicoDerm CQ is OTC
generic is Rx/OTC 24 hours 7mg/14mg/21mg |
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nicotine patch dosing for light smoker
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</= 10 ciggs/day
STEP 2: 14 mg x 6 wks STEP 3: 7 mg x 2 wks |
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NicoDerm CQ heavy smoker dosing
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> 10 ciggs/day
STEP 1: 21mg x 6 wks STEP 2: 14 mg x 2 wks STEP 3: 7 mg x 2 wks |
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Generic nicotine patch heavy smoker dosing
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>10 ciggs/day
STEP 1: 21 mg x 4 wks STEP 2: 14 mg x 2 wks STEP 3: 7 mg x 2 wks |
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Nicotine patch AEs
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1st hour: mild ithcing, burning, & tingling in 50% of patients avoid in psoriasis/eczema = atopic dermatitis
patch removal: skin can be red for 24 hours (>4 days contact MD) vivid dreams/sleep disturbances/HD |
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Nicotine patch pros
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provides consistent nicotine levels
easy to use and conceal QD |
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nicotine patch cons
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patients cannot titrate to manage symptoms
allergic rxns to adhesives do not use if have dermatologic conditions |
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Nicotine Nasal Spray
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10 mL
each metered dose: 50 mcL spray/0.5 mg nicotine 100 doses/bottle rapid absorption across nasal mucosa |
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nicotine nasal spary dosing
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1-2 doses/hour then increase PRN up to 5 doses/hour or 40 mg/1/2 bottle daily
use at least 8 doses/day for 1st 6-8 wks then taper over 4-6 wks [1 dose = 1 mg nicotine/1 spray in each nostril/0.5 mg/nostril] |
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nasal spray
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after dose wait 2-3 minutes before blowing nose
wait 5 minutes before dring or operating heavy machinery avoid contact w/skin/eyes/mouth AEs tearing/coughing/sneezing |
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Nasal spray AEs 1st week
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hot peppery taste in back of throat/nose
sneezing coughing watery eyes runny nose if do not derease after 1 wk contact MD |
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nicotine nasal spray pros
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titrate therapy to manage withdrawal symptoms
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nicotine nasl spray disadvantages
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need for frequent dosing
nasal/throat irritation higher dependence potential not for chronic nasal disorders/severe reactive airway dx |
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nicotine inhaler
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10 mg of nicotine
1 mg of menthol delivers 4 mg nicotine vapor |
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nicotine inhaler dosing
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6 catridges/day for 3-6 wks
increase PRN to max of 16 catridges/day use 1 cartridge Q1-2 hours use for 3 months gradually reduce dose of last 6-12 wks |
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nicotine inhaler catridges
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once open use in 24 hours
nicotine is depleted after about 20 minutes of active puffing not as effective in cold temperatures |
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nicotine inhaler AEs
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mild irritation of throat & mouth
cough HD rhinits dysepsia |
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Nicotine inhaler
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best results w/frequent continueous puffing for 20 minuetes at 1st to control cravings
effectiveness altered by some food/beverages so don't eat/drink 15 minutes before |
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Nicotine inhaler pros
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titrate to manage withdrawal symptoms
mimics hand-to-mouth ritual of smoking |
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nicotine inhaler cons
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frequent dosing
initial mouth/throat irritation don't use cartriges in cold and store in warm use w/caution in bronchospastic dx |
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Bupropion
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Zyban
antidpressant affects levels of dopamine & NE decrease craving for ciggs and symptoms of nicotine withdrawal |
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Bupropion ADME
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bioavailibility: 5-20%
CYP2B6 87% in urine & 10% in feces t1/2 = 21 hours metaboliste t1/2 = 20-37 hours |
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Bupropion SR contraindications
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seizures
taking wellbutrin or MAOIs in last 2 wks dx anorexia or bulimia nervosa drug rehab |
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use Bupropion SR with caution in patients w/
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hx seizures
hx of cranial trauma taking antipsychotics/antidepressants/theophylline/PO steriods which lower seizure threshold severe hepatic cirrhosis depressive/psychiatric disorders |
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Bupropion dosing
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start 1-2 wks before quit date for adequate plasma drug levels!!
150 mg PO Qam x days then 150 mg PO BID for 7-12 wks don't need to taper dose on D/C |
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Bupropion AEs
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insomnia (avoid bedtime dosing!!!)
dry mouth less common: tremor & skin rash |
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Bupropion Pros
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easy to use oral formulation
BID might reduce compliance issues might be beneficial for depression |
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Varenicline warning
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Serious neuropsychiatric events, including, but not limited to depression, suicidal ideation, suicide attempt and completed suicide have been reported in patients taking CHANTIX. Some reported cases may have been complicated by the symptoms of nicotine withdrawal in patients who stopped smoking. Depressed mood may be a symptom of nicotine withdrawal. Depression, rarely including suicidal ideation, has been reported in smokers undergoing a smoking cessation attempt without medication. However, some of these symptoms have occurred in patients taking CHANTIX who continued to smoke.
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Varenicline
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chantix
partial nicotinic receptor antagonis binds to A4B2 subtypes of nueronal nicotinic ACh receptors and stimulates low level agonist activity decreases withdrawal symptoms block dopamine reward |
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Varenicline ADME
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not affected by food
minimal metabolism 92% excreted in urine t1/2 = 24 hours |
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Varenicline dosing
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start 1 wk prior to quit date and titrate dose to minimize nausea and insomia
0.5 mg QD X 3 days then 0.5 mg BID X 3 days then 1 mg BID for rest of tx |
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Varenicline AEs
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nausea
sleep distrubances constipation flatulance vomiting low level agonist - affects of parasympathetic nervous system (rest & digest) |
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D/C chantix
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if agitation, depressed mood, sucidal thoughts, or changes in behavior
do not need dose tapering |
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Varencline
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take after eating w/full glass of water
nausea & insomnia should be temporary if not contact MD |
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Varencline pros
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easy to use oral formualtion
BID new MOA |
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varencline cons
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nausea in 1/3 of patients
nueropsychiatric symptoms |
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2nd line therapies
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clonidine/catapres transdermal/PO
nortriptyline (Pamelor PO) |
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herbal for smoking cessastion
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lobeline
from indian tobacco plant partial nicotinc agonist no evidence |
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combination therapy
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NRT therapy (constant nicotine levels) + short-acting NRT (gum/inhaler/nasal spray) to tx withdrawal symptoms
or buproprion SR + NRT patch |
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state with lowest smoking rate
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Utah at 11%
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state with highest smoking rate
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Kentucky at 30%
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nicotines
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causes endothelial vascularconstriction
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herbal drug for smoking cessastion
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lobeline is partial nicotinc agonist from indian tobacco plant
do not recommend |
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combo therpay
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NRT patch (constant nicotine levels) + short acting NRT (gum/lozeng/nasal spray) for symptoms
or NRT patch + Bupropion |
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nicotine
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causes endothelial vascularconstriction
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smoking
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poor surgical outcomes
decrease paO2 because CO in smoke attacks Hg low birth weight in pregos |
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quit smoking
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cough can last for 1-9 months to clear gunk from lungs
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nicotine
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significant 1st pass metabolism (no PO therapies)
crosses BBB in 11 seonds DI with theophylline which has NTW! |
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cotinine
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metabolite of nicotine
has long t1/2 so is used to determine if someone has been smoking |
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nicotine tolerance causes
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upregulation of nicotinic receptors so have to smoke more ciggs to get same dopamine reward!
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smoking + OCPs with estrogen and progestin
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increased risk of thromboembolism
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Don't use NRT
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pregos category D
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Do not chew more than _ pieces of nicotinic gum due to toxicity
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24 for gum
20 for lozenges (more nicotine) |
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use a minimum of _ pieces/day of nicotinic gum for better outcome
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9
same # w/lozenges better outcomes for both NRTs with dosing scheduel as apposed to PRN use |
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nicotinic gum lasts for
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30 minutes
don't swallow! nicotine irritates GI do not contantly chew and swallow secretions |
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use nicotine patch for
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8 wks
take off 1-2 before bed to prevent insomnia take off for MRI, metallic backing will burn skin! |
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tx rash from nicotinic patch thats present for less than 3 days
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hydrocortisone
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NRT nasal spray
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minmum of 8 doses/day
most rapid delivery of nicotine to brain 10% dependence potential!! NEED TO TAPER TO D/C! |
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wait 10-15 before operating heavy machinery after
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NRT nasal spray due to tearing
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if have asthma do not use
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NRT nasal spray
cause bronchospasm |
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NRT inhaler
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do not inhale into lungs!!cause AEs
min of 6 cartridges/day max of 16 cartridges/day not for airway dx |
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alcholics should use
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NRT patch becasue acidic alcohol will decrease absorption in other NRTs
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after remove NRT wait at least _ hr to smoke due to depot effect
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3 hr
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smoke + pregos
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premes
low birth weight SIDs |
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Bupropion SR
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atypical antidepressant
DI w/ carbamazepine and MAOIs (phenylzine) take in morning and 2nd dose not close to bedtime due to insomnia |
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eating disorders have electrolyte imbalances and are increased risk for seizures when taking
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bupropion SR
only SR has been studies in smoking cessastion! |
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smoke while taking chantix
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will increase incidence of AEs (nausea) because displacing chantix from nicotinic receptors
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Fagerstrom Test for Adults
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how soon do you smoke cigg when wake up?
difficult to refrain from smoking? Can you give up 1st cigg in morning? # ciggs smoke/day smoke more frequently when 1st wake up? smoke when you are ill? |
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max dose of bupropion
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300 mg QD
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