Nicotine Replacement Therapy Pathway- Notes

Jan 2013

Therapy Options

Pharmacological Intervention - Prior to starting a pharmacological therapy assess the following - Previous use of therapy to help smoking cessation - Contraindications and risk of adverse effects (see individual notes and pathways for NRT, Varenicline and Bupropion) - Patient’s age - Availability of support and counseling services - Personal preference of the patient - Interventions combined with counseling increase the quit rate by 1.5 to 2x providing the client is motivated to quit Nicotine Replacement - Is available in several different forms all are equally effective and choice should be guided by personal preference of client and risk of adverse effects. Dose should be chosen by the severity of the withdrawal symptom and the number of cigarettes smoked and adjusted through the course of the treatment Transdermal patches - Available in 16 or 24 hour patches in 3 different doses - 24 hour patches help to reduce craving first thing in the morning - Higher strength patches are more effective for heavy smokers > 10 cigarettes per day - Patch sites should be rotated and emollients used to minimise skin irritation - Patch should be removed if patient experiences side effects or severe local skin reactions Oral Formulations - Inhalator mimics the behavioral aspect of holding a cigarette. Consider reducing from week 7. - Sublingual tablet, two tablets can be taken for heavier smokers - Lozenge, two strengths, higher strength for heavy smokers >20 cigarettes per day - Chewing Gum, two strengths, higher strength for >20 cigarettes per day. Many schools and colleges do not allow chewing gum so may not be suitable for adolescents. Pregnant and breast feeding women should avoid liquorice containing gums - Mouth spray 1-2 sprays to relieve cravings (maximum 4 sprays/hour, 64 in 24hours). Consider reducing number of sprays from week 6 Nasal Formulations - Nasal spray dose 1-2 sprays to each nostril It acts rapidly to deliver nicotine but is more addictive than other forms of NRT. Consider only when other forms of NRT have been tried. - Sneezing and eye watering can be side effects NRT Overdose - The following symptoms may indicate NRT overdose ; abdominal pain, diarrhoea, flushing, nausea, vomiting, headache, dizziness, confusion, visual or hearing disturbances, tachycardia, low blood pressure Bupropion - Is an antidepressant which improves quit rate and reduces withdrawal symptoms in non depressed clients. Refer to Bupropion notes Varenicline - Works at the nicotine receptors to reduce withdrawal symptoms. Commonest side effect is nausea which can be reduced by taking with food. Should be started 1-2 weeks before the quit date

References: BNF 64 September 2012. SPC for all products downloaded Nov 2012. Lothian Joint Formulary downloaded Nov 2012. Tonnessen et al, Efficacy of a nicotine mouth spray in smoking cessation, a randomized double blind trial, Eur Resp Soc, March 2012. Phase three trials on Quickmist (from McNeil rep).