GUIDE FOR USING THE ALGORITHM

(Bader P et al, 2009).

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Three distinct types of pharmacotherapy have demonstrated efficacy as first line medications for smoking cessation:

(a) nicotine replacement therapy (including patch, gum, inhaler, lozenge, nasal spray),

(b) bupropion and

(c) varenicline 

 

Monotherapy

Selecting a particular type of pharmacotherapy should be guided by the following seven factors:

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1. Evidence

• The importance of evidence-based medicine is the top priority in considering which form of pharmacotherapy to prescribe or recommend to a patientbased on effectiveness and safety (Fiore MC  et al, 2008)

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2. Patient preference

• There is no value in prescribing or recommending a medication that a patient will not take. “It is essential that the patient be comfortable with the decision, have reasonable expectations for product efficacy, and have confidence in their ability to use the medication appropriately”.

• Patient preference can be modified through an informed and shared decision-making process between the clinician and patient.

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3. Patient experience

• Expectations are often informed by experience. Therefore, a patient’s experience with smoking cessation attempts and use of pharmacotherapy needs to be a significant factor in influencing choice of pharmacotherapy. “A clinician must understand what the patient has tried and why the patient did not succeed”.

• If the patient was successful with a particular medication for a period of time, it may be prudent to try the same medication again; if unsuccessful with a particular medication, then probably should not use again.

 

4. Patient needs

• Consideration of patient needs is important in determining their willingness to use medications, the ease of use of various smoking cessation products and likelihood of compliance.

• Other patient needs to take into account before prescribing or recommending a particular pharmacotherapy include: extent and severity of cravings, situations or times when cravings are strongest, triggers for smoking, specific hurdles to overcome, etc.

 

5. Patient history

• Many patients have comorbidities (medical, psychiatric, alcohol/drug abuse) which need to be taken into account. For example, a patient with a history of alcohol abuse or seizures would be excluded from bupropion use.

• Smoking history, past quit attempts and experience with pharmacotherapy are all factors influencing the decision of pharmacotherapy choice.

 

6. Patient clinical suitability for pharmacotherapy

• Some patients may not be suitable for pharmacotherapy interventions and potential contraindications need to be considered. Generally, pharmacotherapy would not be recommended for patients having a low level of nicotine dependence.

• In addition, a patient may prefer a non-pharmacological approach to treatment.

 

7. Potential drug interactions/side effects

• Contraindications, use of other medications, and the side effect profile all need to be considered.

• Potential drug interactions are a show-stopper when it is relevant, but it is rarely an issue, so it is important but infrequent”.

 

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Combinations of pharmacotherapy

 Combination pharmacotherapy is indicated for patients based on five factors:

 

1. Failed attempt with monotherapy

• The general principle is that intensity of medications should be increased when monotherapy has resulted in relapse.

• A caveat is that the medication was used appropriately and that there was “a ‘true’ attempt to quit”.

 

2. Patients with breakthrough cravings

• Breakthrough cravings may be an indication that more treatment is needed. An additional form of NRT or an addition of NRT (as needed) to a non-NRT oral medication may be helpful.

• binations of NRT can be used for steady-state delivery (patch) and as needed (gum/lozenge).

 

3. Level of dependence

• Highly dependent smokers are more likely to benefit from combination pharmacotherapy.

• It may be important to begin with combination pharmacotherapy for these individuals.

 

4. Multiple failed attempts

• Multiple failed attempts may be an indication that more intensive therapy is needed.

• However, it is important to keep in mind that failed attempts may also be based on patient lack of commitment rather than insufficient medication.

 

5. Patients with nicotine withdrawal

• Patients experiencing nicotine withdrawal can be a trigger for their relapse to smoking.

• The combination of pharmacotherapies (for example, addition of NRT to another pharmacotherapy) can be a helpful response for managing nicotine withdrawal symptoms.

 

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Specific combinations of pharmacotherapy

When prescribing or recommending combinations of pharmacotherapy, first select combinations of NRT.

Then, prescribe a combination of bupropion and NRT for more heavily dependent patients.

 

1. Two or more forms of NRT

• The use of two or more forms of NRT has the strongest evidence base,  can be used safely and effectively, and is the most commonly used form of combination therapy.

• This approach permits optimal titration of NRT to meet nicotine needs and can be achieved easily and cheaply.

 

2. Bupropion + form of NRT

• Bupropion plus a form of NRT can be effective for some patients.

• This combination is generally used in more heavily dependent patients.

 

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Impact of comorbidities on selection of pharmacotherapy

When prescribing pharmacotherapy to patients having a dual diagnosis (that is, medical, psychiatric or other substance use in addition to smoking), specific attention should be given to:

 

1. Contraindications

• Attention to contraindications is the top priority in the selection of type of pharmacotherapy in patients with comorbidities

• Contraindications are primarily an issue with use of bupropion (that is, history of seizures, alcohol problems) and with patients who are already taking other medications.

 

2. Specific pharmacotherapy useful for certain comorbidities

• Specific pharmacotherapy may be useful for treatment of certain comorbidities in addition to smoking cessation.

• For example, bupropion may be a good choice for depressed patients who want to quit smoking. However, for patients with anxiety disorders or eating disorders, bupropion would not be a good choice.

 

3. Dual purpose medications

• Dual purpose medications may have added value in enhancing compliance. 

• Most common is use of bupropion for depressed patients who want to quit smoking. Bupropion can also be useful for patients who do not want to gain weight.

 

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Frequency of monitoring

All patients taking pharmacotherapy should be monitored carefully.

The frequency of monitoring should be determined by:

 

1. Patient need

• The top priority for frequency of monitoring should be determined by patient needs. For example, patients with multiple or difficult quit attempts will likely require more support.

 

2. Type of pharmacotherapy

• Some types of pharmacotherapy may require more frequent monitoring, particularly if there is potential for adverse events (for example, drug interaction, side effects).