Mayo Clinic ndc tobacco Dependence Treatment Medication Summary




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Mayo Clinic NDC Tobacco Dependence Treatment Medication Summary

Description & Examples

Pros & Cons


Comments

Dosing Recommendations

Combination Nicotine Replacement Therapy

(NRT)


Pros

  • Permits sustained levels of nicotine with rapid adjustment for acute needs

Cons


  • May increase risk of nicotine toxicity

  • Cost

Comments/limitations

Providing two types of delivery system, one passive and one active, appears to be more efficacious. Should be considered for those who have failed single therapy in the past and those considered highly tobacco dependent.

Not a FDA approved strategy.


Dosing**

Dose the patch as described. Prescribe 2mg gum, 2 mg lozenge, nicotine inhaler or nicotine nasal spray on an as needed basis when acute withdrawal symptoms and urges to use tobacco occur. Adjust dose of patch if frequent use of other NRT: goal is to minimize need for short-acting NRT dosing.


Nicotine Patch

(OTC)



24 hour delivery systems

21, 14, 7 mg/24 hr


16 hour delivery systems

15 mg/16 hr


(Generic available)

Pros

  • Achieve high levels of replacement

  • Easy to use

  • Only needs to be applied once a day

Cons

Comments/limitations

Patches vary in strengths and the length of time over which nicotine is delivered. Depending on the brand of patch used, may be left on for anywhere from 16 to 24 hours. Patches may be placed anywhere on the upper body-including arms and back. Rotate the patch site each time a new patch is applied.


May purchase without a prescription


Dosing** (24 hour patch)

>40 cpd = 42 mg/day

21-39 cpd = 28-35 mg/day

10-20 cpd = 14-21 mg/day

<10 cpd = 14 mg/day

Nicotine Lozenge



(OTC)
Delivers nicotine through the lining of the mouth while the lozenge dissolves.

2 mg, 4 mg




Pros

  • Easy to use

  • Delivers doses of nicotine approximately 25% higher than nicotine gum

Cons

  • Should not eat or drink 15 minutes before use or during use

  • Should not be chewed or swallowed

  • Nausea frequent (12-15%)


Comments/limitations

Use at least 8-9 lozenges/day initially. Efficacy and frequency of side-effects related to amount used.



May purchase without a prescription


Dosing as Monotherapy

Based on time to first cigarette of the day:



<30 minutes = 4 mg

>30 minutes = 2 mg
Based on cigarettes/day (cpd)

>20 cpd: 4 mg



<20 cpd: 2 mg

Initial dosing is 1-2 lozenges every 1-2 hours (minimum of 9/day).

Taper as tolerated

Nicotine Gum

(OTC)

2mg, 4mg


Flavors: Orange, Mint, Regular
The term “gum” is misleading. It is not chewed like regular gum but rather is chewed briefly and then “parked” between cheek and gum. The nicotine is absorbed through the lining of the mouth.

(Generic Available)



Pros

  • Convenient/Flexible dosing

  • Faster delivery of nicotine than the patches

Cons

  • May be inappropriate for people with dental problems and those with temporomandibular joint (TMJ) syndrome

  • Should not eat or drink 15 minutes before use or during use

  • Frequent use during the day required to obtain adequate nicotine levels


Comments/limitations

Many people use this medication incorrectly. Review package directions carefully to maximize benefit of product


May purchase without a prescription


Dosing as Monotherapy**

Based on cigarettes/day (cpd)

>20 cpd: 4 mg gum

<20 cpd: 2 mg gum

Based on time to first cigarette of the day:



<30 minutes = 4 mg

>30 minutes = 2 mg

Initial dosing is 1-2 pieces every 1-2 hrs (10-12 pieces/day).
Taper as tolerated.

Description & Examples


Pros & Cons

Comments

Dosing Recommendations

Nicotine Nasal Spray


Delivers nicotine through the lining of the nose when sprayed directly into each nostril.


Pros :

  • Flexible dosing

  • Can be used in response to stress or urges to smoke

  • Fastest delivery of nicotine of currently available products but not as fast as cigarettes

Cons

  • Nose and eye irritation is common, but usually disappears within one week.

  • Frequent use during the day required to obtain adequate nicotine levels

Comments/limitations

Unlike nasal sprays used to relieve allergy symptoms, the nicotine spray is not meant to be sniffed. Rather, it is sprayed against the lining of each nostril once or twice an hour (maximum of five times in one hour).


Prescription required for purchase


Dosing as Monotherapy

1 spray in each nostril

1-2 times/hr

(up to 5 times/hr or 40 times/day)


Most average 14-15 doses/day initially
Taper as tolerated

Nicotine Inhaler

A plastic cylinder containing a cartridge that delivers nicotine when puffed. The inhaler delivers nicotine to the oral mucosa, not the lung, and enters the body much more slowly than the nicotine in cigarettes.


Pros

  • Flexible dosing

  • Mimics the hand-to-mouth behavior of smoking

  • Few side effects

Cons

  • Frequent use during the day required to obtain adequate nicotine levels

  • May cause mouth or throat irritation

Comments/limitations

Puffing must be done frequently, far more often than with a cigarette. Each cartridge designed for 80 puffs over 20 minutes of use. Patient does not need to inhale deeply to achieve an effect.


Prescription required for purchase


Dosing as Monotherapy

Minimum of 6 cartridges/day,

up to 16/day
Taper as tolerated

Non-nicotine medication




Bupropion SR

(Generic Available)



Pros

  • Easy to use

  • Pill form

  • Few side effects

  • May be used in combination with NRT (nicotine patches, spray, gum and inhaler)**

Cons

  • Contraindicated with certain medical conditions and medications

Comments/limitations

A slight risk of seizure (1:1000) is associated with use of this medication. Seizure risk should be assessed. Risk of seizure is increased if:



  • Personal history of seizures

  • Significant head trauma/brain injury

  • Anorexia nervosa or bulimia

  • Concurrent use of medications that lower the seizure threshold

Prescription required for purchase

Dosing: Take doses at least 8 hours apart

Start medication one week prior to the Target Quit Date (TQD)



150 mg once daily for 3 days, then

150 mg twice daily for 4 days, then
On TQD STOP SMOKING
Continue at 150 mg BID 12 weeks, or longer if necessary. May stop abruptly; no need to taper.

Non-nicotine medication




Varenicline





Pros

Cons

  • Nausea is common




Comments/limitations

  • Nausea is common. Taking the medication with food and titrating the dose as directed will help

  • It appears that varenicline can be safely used in combination with bupropion and/or NRT. However, efficacy of these combinations has not been shown

  • Dose must be adjusted if kidney function is impaired

Prescription required for purchase


Dosing: TAKE WITH FOOD

Start medication one week prior to the Target Quit Date (TQD)



0.5 mg once daily X 3 days, then

0.5 mg twice daily X 4 days, then

ON TQD STOP SMOKING AND

Take 1.0 mg twice daily X 11 weeks

If not smoking at the end of twelve weeks, may continue at 1.0 mg twice daily for an additional 12 weeks

May stop abruptly. No need to taper.











SMOKELESS TOBACCO (ST)

Treatment Recommendations

24 hour nicotine patch:

>3 cans or pouches/week = 42 mg/day

2-3 cans or pouches/week = 21 mg/day

<2 cans or pouches/week = 14 mg/day

Adjust based on withdrawal symptoms, urges, and comfort. After 4-6 weeks of abstinence, taper every 2-4 weeks in 7-14 mg steps as tolerated


Other NRT:

Nicotine lozenge: 4mg if > 3 tins/week

2mg if < 3 tins/week Nicotine gum or nicotine lozenge may be combined with nicotine patch as described for cigarette smokers. Nicotine inhaler and nicotine nasal spray are not recommended for use in ST users.


Non-nicotine pharmacotherapy

Empiric evidence suggests that bupropion and varenicline may be of benefit in this population of tobacco users, using the dosing guidelines recommended for cigarette smokers.



The table is a summary of recommendations for use of medication in the treatment of tobacco dependence. The most effective dose varies by individual. Costs will vary depending on retailer. (**Some of the dosing recommendations are not contained in current product labeling information). Adapted from Ebbert JO, et al. J Thorac Oncol.2007;2:249-256; Fiore, et.al. U.S. Public Health Service Guideline , June 2000; Schiffman et. Al. Archives of Internal Medicine 2002;162:1267-1276. Varenicline Product Information profile (May,2006) Revised November2007


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