Medical Directive: Prescribing Medications for Smoking Cessation Medical Directive MMPC02 Personnel:

Clinical pharmacist or approved nurse with advanced training in TEACH (Training Enhancement Applied Cessation Counselling in Health)

Designated Act:  Initiation and renewal of smoking cessation aids as a pharmaceutical option for Smoking Cessation adjunctive therapy for patients with no known contraindications and who are being counselled for smoking cessation by a Clinical Pharmacist  includes Zyban, Champix and over-the counter nicotine replacement (NRT) products

Clinical Conditions:  Smokers who are in preparation/ action stage of readiness to quit their habit of smoking  Offered as a smoking cessation aid option in conjunction with behavioural modification strategies and support  Patients willing and able to follow up with pharmacist on a predetermined date  Able to access alcohol use, illicit drug use, sedation or BZD use (do not abruptly stop)

Process

 Assess patient’s readiness to change smoking cessation habits and history of smoking includes past attempts. If in preparation/ action stage set Stop Smoking Date  Assess Nicotine Addiction using Revised Fagerstrom Nicotine Addiction Scale  If rating is > 3/10 review Pharmaceutical Options including Nicotine Replacement Therapy (NRT) replacement  Assess if any contraindications to Zyban, Champix, NRT  Ensure other smoking cessation strategies (behaviour modification and supportive) are in place for Stop Smoking Date  Arrange follow up appointment soon after stop smoking dated or at least within 1- 2 weeks via telephone

Prescribing: Zyban

 If choosing Zyban prescribe 150mg daily X3 days (starting 1 week prior to stop smoking date), then increase to 150mg BID (to stop smoking between day 7 and 10). Prescribe: 1 month supply  Advice to not take Zyban any closer than 8 hours apart as increased seizure risk  Ensure other smoking cessation strategies (behaviour modification and supportive) are in place for Stop Smoking Date  With close supervision therapy may continue 3-6 months. If within 3 months patient has not stopped smoking, stop therapy and offer alternatives, setting another stop date with support

Contraindications:  Known hypersensitivity to Buproprion  Already being treated with Wellbutrin SR for depression  History of a seizure disorder  History of eating disorder- bulimia or anorexia nervosa  Current treatment with MAO inhibitors, Thioridazine (within 14 days), St. John’s Wort  Pregnant (1st Trimester)  Lactation  Under 18 years old  Alcoholism, opiate addiction  Impaired liver or kidney function  Caution within recent MI, unstable heart disease, uncontrolled hypertension, risk of seizure (e.g. history of head trauma)  Caution with meds that lower seizure threshold e.g. antipsychotic, antidepressants, Lithium, Amantadine, Theophylline, systemic steroids, Quinolone antibiotics and antimalarials, OTC stimulants or anorectics , diabetes treated with oral hypoglycemic agents or insulin

Precautions:  Single dose may not exceed 150mg closer than 8 hours apart (increase seizure threshold)  Daily total dose may not exceed 300mg  Insomnia may be minimized by avoiding bedtime doses (last dose by 1800)

Prescribing: Champix

 If choosing Champix, prescribe 0.5mg daily days 1-3 (starting 1-2 weeks prior to stop smoking date), 0.5mg BID days 4-7 then 1.0mg BID days 8 –End of treatment. Prescribe: 1 month supply  Advice to patients who cannot tolerate adverse effects of Champix may have the dose lowered temporarily or permanently  Patients to be advised to set a date to stop smoking  Dose to be adjusted in patients with severe renal impairment (CrCl<30mL/min). Dose of Champix is 0.5mg daily days 1-3 then increased to 0.5mg BID thereafter  Duration of treatment is 12 weeks. For patients who have successfully stopped smoking at the end of 12 weeks, an additional course of 12 weeks treatment with Champix may be considered  Ensure other smoking cessation strategies (behaviour modification and supportive) are in place for Stop Smoking Date

Contraindications:  Patients who are hypersensitive to varenicline or to any ingredient in the formulation or component of the container  Patients < 18 years of age  Pregnancy or lactation 

Precautions:  Total daily dose may not exceed 2mg  The concomitant use of NRT may result in increase in adverse reactions including nausea, headache, vomiting, dizziness, dyspepsia and fatigue  Smoking cessation with or without varenicline may alter pharmacodynamics or pharmacokinetics of some drugs for which dosage adjustment may be necessary (including but not limited to theophylline, warfarin and insulin). Smoking cessation may result in increase plasma levels of CYP 1A2 substrates  Caution patient may cause mild to moderate nausea, most often transient but for some, may persist over several months  May cause dizziness or somnolence

Prescribing: Nicotine Replacement Therapy (NRT)

 Patients will be offered the choice of NRT products available  21mg patch should be offered to a patient who smokes an average of 10 or more cigarettes per day. Duration is generally 6 weeks on 21mg , 2 weeks on 14mg and 2 weeks on 7mg  Gum is available as 2mg and 4mg. Appropriate strength will be determined by the Revised Fagerstrom Nicotine Addiction Scale.  Prescribing NRT is within the scope of practice of a pharmacist

Contraindications:  Patients with hypersensitivity or allergy to nicotine or the components of the transdermal system  Non-smokers  Occasional smokers (patch only)  Patients < 18 years of age  Patients with life threatening arrhythmias, patients with severe or worsening angina pectoris  Patients who have had recent cerebral vascular accident  Pregnancy and lactation  Patients with generalized skin disorders (patch only) Precautions:  Caution patients if they continue to smoke while using NRT may experience adverse effects due to peak nicotine levels higher than those experience with smoking alone.  Patients are asked to rotate the site of patch application daily to prevent/ minimize local irritation

Approval by Board of Directors GMC FHT:

 Dr ______ Dr ______ Dr ______

Authorizing Physicians:

Dr