Introduction to pharmacotherapy

Dr. Shamim Jubayer. Research Fellow

Dept. Epidemiology and Research National Heart Foundation Hospital And research Institute

Effective tobacco cessation medications

• The currently available effective tobacco cessation medications are:

− nicotine replacement therapy (NRT): nicotine gum, nicotine patches, nicotine nasal spray, nicotine inhaler, nicotine lozenges/sublingual tablets;

− non-nicotine medications: bupropion sustained release (SR), varenicline, cytisine, clonidine, triptyline

How to assess a tobacco user’s level of nicotine dependence

Assessing a tobacco user’s level of nicotine dependence can help primary care providers prescribe or recommend a dosage of NRT to tobacco users.

• There are two ways to assess the level of nicotine dependence:

Using the Fagerström Test

Asking two simple questions:

• How many cigarettes do you smoke per day?

• At what time do you smoke your first cigarette in the morning?

• Using the Fagerström Test • This is the standard instrument for assessing the intensity of physical

addiction to nicotine Scoring:

– 0−2 = very low dependence – 3−4 = low dependence – 5 = medium dependence – 6−7 = high dependence – 8−10 = very high dependence.

• Scores under 5: “Your level of nicotine dependence is still low. You should act now before your level of dependence increases.”

• Score of 5: “Your level of nicotine dependence is moderate. If you don’t quit soon, your level of dependence on nicotine will increase until you may be seriously addicted. Act now to end yourdependence on nicotine.”

• Score over 5: “Your level of dependence is high. You are not in control of your smoking - it is in control of you! When you make the decision to quit, you may want to talk with your doctor about nicotine replacement therapy or other medications to help you break your addiction.”

Asking two simple questions:

How many cigarettes do you smoke per day?

• A < 10 cpd; B 10−20 cpd; C 21−39 cpd; D > 40 cpd.

• At what time do you smoke your first cigarette in the morning?

• A <_ 30 minutes after waking up; B > 30 minutes after waking up.

Recommendations for use of NRT products in the treatment of tobacco dependence

When you prescribe or recommend NRT products for tobacco users you will need to give them clear instructions and dosing recommendations.

Prescribing NRT products

There are several medications available for treating tobacco dependence. Currently NRT has the best balance of effectiveness, cost and safety. As a result, two forms of NRT (nicotine gum and nicotine patch) have been added to the WHO Model List of Essential Medicines. Dosing recommendation of NRT products should be made based on the tobacco user’s level of nicotine dependence

* Only Nicotine gum is available in Bangladesh (in 2 mg and 4 mg strengths). ** For pregnant and lactating mothers, shorter-acting NRTs such as gums are recommended. *** NRT can be prescribed to persons with underlying stable cardiovascular disease, including angina and previous myocardial infarction.

TOBACCO CESSATION IN SPECIAL SITUATIONS

• Pregnant and lactating females

• Women who use tobacco during pregnancy and breast-feeding should strongly be advised against it. They should be asked to quit using the behavioral strategies that were mentioned earlier, to deal with withdrawal. However if they are unable to quit just by behavior counseling, then use of NRT may be considered. Pregnant and breast-feeding women who opt for NRT should be advised to use shorter acting products to minimize overnight foetal exposure to nicotine. (e.g. Nicotine gum)

• Cardiovascular disease • In stable cardiovascular disease conditions, use of NRT is safe.

Caution should be taken while considering NRT in patients of unstable angina, myocardial infarction, or stroke as nicotine is a vasoconstrictor. In these cases, rapidly reversible NRT like nicotine gum is preferable.

• Patients with tobacco use related diseases • This is a group where tobacco cessation is an urgent clinical need, as

continued tobacco use greatly increases the risk of further illness. There is evidence that pharmacotherapy with bupropion can increase cessation rates in chronic tobacco users with co-morbidity and those with mild to moderate Chronic Obstructive Pulmonary Disease. People with tobacco use related diseases may benefit from a multidisciplinary care plan.

• Patients with mental illness

• Persons with substance-use disorders

• Tobacco users with apprehension of weight gain.

Ref .National Tobacco Control Programme,Directorate General of Health Services Ministry of Health & Family Welfare Government of India