4.10.2 Nicotine dependence

Bupropion

Bupropion
  • Tablets 150mg (£41.76 = 60 tablets)

Dose

  • Start 1–2 weeks before target stop date
  • Initially 150 mg daily for 6 days, then 150 mg twice daily
  • Treatment duration: 7–9 weeks. Discontinue if abstinence not achieved at 7 weeks
  • Elderly: maximum 150mg daily
  • Risk factors for seizures: consider maximum dose of 150 mg daily (see note 5 below)

Notes

  1. Bupropion is licensed as an adjunct to smoking cessation in combination with motivational support in adults.
  2. Bupropion has been associated with seizures (see note 5 below), which occur in around 1 in 1,000 patients treated (0.1%).
  3. Insomnia is a very common adverse event which can be reduced by avoiding bedtime doses of bupropion (provided there is at least 8 hours between doses).
  4. Patients should exercise caution before driving until they know whether bupropion affects their ability to drive.
  5. Bupropion is contra-indicated in patients with a history of seizures or of eating disorders, a CNS tumour, or who are experiencing acute symptoms of alcohol or benzodiazepine withdrawal. Bupropion should not be prescribed to patients with other risk factors for seizures unless the potential benefit of smoking cessation clearly outweighs the risk. Factors that increase the risk of seizures include concomitant administration of drugs that can lower the seizure threshold (anti-depressants, antimalarials, antipsychotics, quinolones, sedating antihistamines, systemic corticosteroids, theophylline and tramadol), alcohol abuse, history of head trauma, diabetes, and use of stimulants and anorectics.
  6. MHRA Drug Safety Update (November 2020): Bupropion (Zyban): risk of serotonin syndrome with use with other serotonergic drugs
    • cases of serotonin syndrome have been reported in association with bupropion and co-administration with serotonergic drugs, for example
      • selective serotonin re-uptake inhibitors (SSRIs)
      • serotonin norepinephrine re-uptake inhibitors (SNRIs)
    • if concomitant prescribing with other serotonergic drugs is clinically warranted
      • do not exceed the recommended dose
      • remind patients of the milder symptoms of serotonin syndrome at initiation of treatment and at any change of dose and the importance of seeking medical advice if they occur
      • if serotonin syndrome is suspected, either decrease the dose of bupropion or withdraw therapy depending on the severity of the symptoms
    • Advice to give to patients
      • if you are told you may be at risk of serotonin syndrome, be aware of symptoms, including mild signs such as nausea, vomiting, and diarrhoea or increased heart rate and agitation (see Drug Safety Update for full list) and talk to your prescriber if you experience these
      • never exceed the prescribed dose of bupropion

To optimise the results from smoking cessation programmes it is advised that patients access motivational support from the Devon Specialist Stop Smoking Service (01884 836 024).

Suggested plan for providing smoking cessation therapy

  • Patient must demonstrate motivation and willingness to quit. Adverse comments about the cost of therapy or refusal of first line options may lead one to question the motivation. If insufficient motivation apparent, offer information and help so that the patient may return to the service when ready.
  • If the patient has previously failed attempts to quit using NRT, discuss reasons for failure. NICE guidance PH10 (Smoking cessation services) recommends that the NHS should not normally fund a second attempt to quit within 6 months of a failed attempt, but if external factors have interfered with that attempt, it may be reasonable to try again sooner.
  • If indicated offer NRT. Explain that this doubles the chance of quitting but that will power and motivation are very important. Receiving NHS behavioural support may double these chances again.
  • If NRT is not suitable, consider the use of bupropion or varenicline.
  • Smoking cessation therapies should only be prescribed where the smoker sets a 'quit date'. Initial prescriptions should provide medication to last only until 2 weeks past the quit date (normally 2 weeks after the start of NRT or 3-4 weeks after the start of bupropion or varenicline).
  • It is recommended that NRT products be prescribed in the following intervals: 2 weeks; 2 weeks; 4 weeks; 4 weeks.
  • 'Cut down to quit' regimens are not recommended (see below for more details).
  • If patient is not abstinent at 8 weeks, consider withdrawing NRT/ bupropion/varenicline.
  • Commence step down strengths where appropriate to the particular product being used.
  • Follow patient up at 4 weeks or more past their quit date to assess smoking status. Record status on the patient's completed monitoring form/ computerised record and return it to the Public Health Information Team (PHIT) at County Hall, Exeter.
  • Use the Fagerström questionnaire to assess the level of dependency (see below).

Nicotine replacement therapy (NRT)

It is strongly recommended to provide short duration prescriptions (fortnightly) in early stages of the quit attempt. This can be linked to motivational support and will help reduce potential wastage. For patients who pay for their prescriptions, a 3-monthly pre-payment certificate may prove advantageous.

See notes at the bottom of the page for more information on NRT.

Transdermal NRT

Patches should be applied to dry non-hairy skin. The site of application should be rotated, avoiding the same area for several days.

Nicorette® Invisi patch
  • Invisi patch 10mg, 15mg, 25mg – 16 hour patch (£20.74 = 14 days)

Dose

  • Very High / High dependence, (Fagerström score = 7 – 10, more than 10 cigarettes per day)
    • 25mg x 8 weeks
    • 15mg x 2 weeks
    • 10mg x 2 weeks
  • Moderate dependence (Fagerström score = 4-6, less than 10 cigarettes per day)
    • 15mg x 8 weeks
    • 10mg x 4 weeks
  • Low dependence (Fagerström score = 1-3)
    • Not appropriate

Notes

  1. The 16-hour patch should normally be applied on waking and removed on retiring to bed. Its use may help avoid the vivid dreams and sleep disturbance, which may be associated with the 24-hour patches.
NiQuitin® patch
  • Patches 7mg, 14mg, 21mg – 24 hour patch (£19.94 = 14 days)

Dose

  • Very High / High dependence, (Fagerström score = 7 – 10, more than 10 cigarettes per day)
    • 21mg x 6 weeks
    • 14mg x 2 weeks
    • 7mg x 2 weeks
  • Moderate dependence (Fagerström score = 4-6, less than 10 cigarettes per day)
    • 14mg x 6 weeks
    • 7mg x 2 weeks
  • Low dependence (Fagerström score = 1-3)
    • Not appropriate

Notes

  1. The 24-hour patches may be more suitable for those who experience cravings within the first 30 minutes of waking.
Nicotinell® patch
  • TTS Patches '10', '20', '30' – 24 hour patch (£19.94 = 14 days x '30')

Dose

  • Very High / High dependence, (Fagerström score = 7 – 10, more than 10 cigarettes per day)
    • 21mg x 3-4 weeks
    • 14mg x 3-4 weeks
    • 7mg x 3-4 weeks
  • Moderate dependence (Fagerström score = 4-6, less than 10 cigarettes per day)
    • 14mg x 3-4 weeks
    • 7mg x 3-4 weeks
  • Low dependence (Fagerström score = 1-3)
    • Not appropriate

Notes

  1. The 24-hour patches may be more suitable for those who experience cravings within the first 30 minutes of waking.

As required NRT

Nicorette® Gum
  • Chewing gum 2mg, 4mg, 6mg (6mg = £24.24, 15 pieces daily for 14 days)

Dose

  • Use 4mg or 6mg strength for very high or highly dependent patients, 2mg gum is more appropriate for moderate to low dependent
  • Maximum 15 pieces/day

Notes

  1. One piece of gum should be chewed slowly when the individual feels the urge to smoke. When the taste becomes strong the gum should be 'parked' between the gum and cheek until the taste subsides after which it should be re-chewed. The gum will become exhausted after about 30 minutes.
  2. Small pack sizes are available, but these work out more costly per piece of gum than the larger packs. The products are available in a range of flavours.
Nicotinell® Gum
  • Chewing gum 2mg, 4mg (4mg = £22.44, 15 pieces daily for 14 days)

Dose

  • Use 4mg strength for high to very high dependency patients, 2mg gum is more appropriate for moderate to low dependency
  • Maximum 15 pieces/day

Notes

  1. One piece of gum should be chewed slowly when the individual feels the urge to smoke. When the taste becomes strong the gum should be 'parked' between the gum and cheek until the taste subsides after which it should be re-chewed. The gum will become exhausted after about 30 minutes.
  2. Small pack sizes are available, but these work out more costly per piece of gum than the larger packs. The products are available in a range of flavours.
  3. Liquorice-flavoured gum should not be used in pregnancy
NiQuitin® gum
  • Chewing gum 2mg, 4mg (4mg = £18.70, 15 pieces daily for 14 days)

Dose

  • Use 4mg strength for very high or highly dependent patients, 2mg gum is more appropriate for moderate to low dependent
  • Maximum 15 pieces/day

Notes

  1. One piece of gum should be chewed slowly when the individual feels the urge to smoke. When the taste becomes strong the gum should be 'parked' between the gum and cheek until the taste subsides after which it should be re-chewed. The gum will become exhausted after about 30 minutes.
  2. Small pack sizes are available, but these work out more costly per piece of gum than the larger packs. The products are available in a range of flavours.
Nicotinell® lozenge
  • Mint lozenge 1mg, 2mg (2mg = £23.16, 15 daily for 14 days)

Dose

  • Use 2mg strength for high to very high dependency patients, 2mg lozenges are more appropriate for moderate to low dependency
  • Maximum 15 lozenges/day

Notes

  1. Suck lozenge until taste becomes strong, then rest lozenge between gum and cheek. Repeat once the taste fades.
NiQuitin® lozenge
  • Original or mint lozenge 2mg, 4mg (4mg = £29.08, 15 daily for 14 days)

Dose

  • Maximum 15 lozenges/day

Notes

  1. Suck lozenge until taste becomes strong, then rest lozenge between gum and cheek. Repeat once the taste fades.
Nicorette Microtab®
  • Tablets (sublingual) 2mg (£73.47 = 40 daily for 14 days)

Dose

  • Very High / High dependence: 2mg tab, two per hour. Up to 40 tablets/day
  • Moderate / Low dependence: 2mg tab, one per hour. Up to 15 tablets/day
Nicorette® Inhalator
  • Inhalator 15mg (£56.07 = 14 days)

Dose

  • Insert the cartridge into the device and draw in air through the mouthpiece; each session can last for approximately 5 minutes
  • A single 15mg cartridge lasts for approximately 40 minutes of intense use
  • Patients should not exceed 6 cartridges of the 15mg strength daily

Notes

  1. Patients with obstructive lung disease may find use of the Inhalator difficult. An alternative formulation of NRT may be preferred in such cases.
  2. The Inhalator should be used with caution in patients with chronic throat disease or bronchospastic disease.
Nicorette® Nasal Spray
  • Nasal spray 500 micrograms/spray (£13.40 = 10mL)

Dose

  • Patients can use 1 spray in each nostril when the urge to smoke occurs, up to twice every hour for 16 hours daily
  • Maximum 64 sprays daily

Notes

  1. Use of the nasal spray in patients with hyper-reactive airways is not recommended as cases of exacerbation of bronchospasm have been reported in patients with bronchial asthma.

Varenicline

Varenicline
  • Tablets 500 micrograms, 1mg (£27.30 = 28 tablets)
  • Starter pack (2 weeks treatment) 11 tablets 500 micrograms plus 14 tablets 1mg (£27.30)

Dose

  • Initially 500 micrograms once daily for 3 days, increased to 500 micrograms twice daily for 4 days, then 1 mg twice daily for 11 weeks (reduce to 500 micrograms twice daily if not tolerated)

Notes

  1. See NICE TA123- Smoking cessation - varenicline (July 2007)
  2. Supply Disruption Alert 24 June 2021 (SDA/2021/006): All Champix® (varenicline) products are unavailable until further notice. Actions to be taken:
    1. Patients currently prescribed this treatment will require review and switching to nicotine replacement therapy (NRT) unless contraindicated. See alert for further information
    2. No new patients should be initiated on Champix® (varenicline) products
    3. Prescribers initiating smoking cessation treatment for new patients should consider prescribing NRT or bupropion 150mg prolonged release tablets unless contraindicated
  3. Varenicline is not licensed for use in children or adolescents.
  4. Dose adjustment is necessary in severe renal impairment (see SPC).
  5. Combination with other smoking cessation therapies has not been adequately studied to be considered for use.
  6. Up to a third of patients may experience nausea. Other troublesome adverse effects include insomnia, abnormal dreams and headaches.
  7. Discontinuation of treatment is associated with an increase in irritability, urge to smoke, depression and/or insomnia in up to 3% of patients (see note 9 below).
  8. Clinical trials involving varenicline excluded patients with significant co-morbidity that may be present in a population of smokers such as severe cardiovascular disease, uncontrolled hypertension and COPD. Patients with epilepsy were also excluded.
  9. Patients should be advised not to drive until it is known whether varenicline affects their ability to drive.
  10. Suicidal behaviour and varenicline, MHRA/CHM advice: Patients should be advised to discontinue treatment and seek prompt medical advice if they develop agitation, depressed mood, or suicidal thoughts. Patients with a history of psychiatric illness should be monitored closely while taking varenicline

 

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