36.94 Physician Pharmacologic Guidelines

Diabetes Planned Visit Notebook

This table provides care providers a side-by-side comparison of medications currently available to help smokers quit using tobacco. It is part of the Diabetes Planned Visit Notebook.

Suggestions for the Clinical Use of Pharmacotherapies for Smoking Cessation

PharmacotherapyPrecautions/
Contraindications
Side EffectsDosageDurationAvailability*Cost
Bupropion SRHistory of seizure
History of eating disorders
Insomnia
Dry mouth
150 mg every morning for 3 days, then 150 mg twice daily. (Begin treatment 1-2 weeks pre-quit)7-12 weeks
Maintenance up to 6 months
Zyban (prescription only)$137 for 60 pills (range=$89 for generic—153 for Zyban)
Nicotine Gum Mouth soreness
Dyspepsia
1-24 cigs/day: 2mg gum (up to 24 pcs/day) 25+ cigs/day: 4 mg gum (up to 24 pcs/day)Up to 12 weeksNicorette, Nicorette Mint, Nicorette Orange (OTC only), Generic2 mg starter pack (108 pcs) - $50
4 mg starter pack (108 pcs) - $55
Nicotine Inhaler Local irritation of mouth and throat6-16 cartridges/dayUp to 6 monthsNicotrol Inhaler (prescription only)$152 for 168 cartridges
Nicotine Nasal Spray Nasal irritation8-40 doses/day3-6 monthsNicotrol NS (prescription only)$44 (range=$36-$52)
Nicotine Patch Local skin reaction
Insomnia
21 mg/24 hrs
14 mg/24 hrs
7mg/24 hrs
15 mg/16 hrs
4 weeks
then 2 weeks
then 2 weeks
8 weeks
Nicoderm CQ (OTC only), Generic patches (prescriptions and OTC) Nicotrol (OTC only)$45-$50 for each step
Nicotine Lozenge Insomnia, nausea, hiccups, coughing, heartburn, headache and flatulence.1 lozenge every 1-2 hours
1 lozenge every 2-4 hours
1 lozenge every 4-8 hours

6 weeks

Weeks 7-9

Weeks 10-12

Commit (OTC)$43 for 72 lozenges

*Prices based on average retail prices of medication at various Summit County retail pharmacies, September 2004.
Note: The information contained within this table is not comprehensive. Please see package insert for additional information.
Provided courtesy of Summit County Tobacco Prevention Coalition

Clinical Guidelines for Prescribing Pharmacotherapy for Smoking Cessation

Treating Tobacco Use and Dependence

Who should receive pharmacotherapy for smoking cessation?

All smokers trying to quit except in the presence of special circumstances. Special populations who should be given special consideration include: those with medical contraindications, those smoking less than 10 cigarettes per day, pregnant, and adolescent smokers,

What are the first-line pharmacotherapies recommended in this guideline?

All give of the FDA-approved pharmacotherapies for smoking cessation are recommended including bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, and the nicotine patch.

What factors should a clinician consider when choosing among the five first-line pharmacotherapies?

Because of the lack of sufficient data to rank-order these five medications, choice of a specific first-line pharmacotherapy must be guided by factors such as clinician familiarity with the medications, contraindications for selected patients, patient preference, previous patient experience with a specific pharmacotherapy (positive or negative), and patient characteristics (e.g., history of depression, concerns about weight gain).

Are pharmacotherapies treatments appropriate for lighter smokers (e.g., 10-15 cigarettes per day)?

If pharmacotherapy is used with lighter smokers, clinicians should consider reducing the dose of first-line pharmacotherapies.

What second-Iine pharmacotherapies are recommended in this guideline?

Clonidine and nortriptyline.

When should second-line agents be used for treating tobacco dependence?

Consider prescribing second-line agents for patients unable to use first-line medications because of contraindications or for patients for whom first-line medications are not helpful. Monitor patients for the known side effects of second-line agents.

Which pharmacotherapies should be considered with patients concerned about weight gain?

Buproprion SR and nicotine replacement therapies (NRT), in particular nicotine gum, have been shown to delay, but not prevent, weight gain.

Which pharmacotherapies should be considered with patients with a history of depression?

Bupriopion SR and nortriptyline appear to be effective with this population.

Should nicotine replacement therapies be avoided in patients with a history of cardiovascular disease?

No. NRT is safe have not been shown to cause adverse cardiovascular effects. However, the safety of these products has not been established for the immediate post-MI period or in patients with severer or unstable angina.

May tobacco dependence pharmacotherapies be used long-term (6 months or more)?

Yes. This approach may be helpful with smokers who report persistent withdrawal symptoms during the course of pharmacotherapy or who desire long-term therapy. A minority of individuals who successfully quit smoking use ad libitum NRT medications (gum, nasal spray, inhaler) long-term. The use of the medications long-term does not present a known health risk. Additionally, the FDA has approved the use of bupropion SR for a long-term maintenance indication.

May nicotine replacement pharmacotherapies ever be combined?

Yes. There is evidence that combining the nicotine patch with either nicotine gum or nicotine nasal spray increases long-term abstinence rates over those produced by a single form of NRT.

From the U.S. Dept of Health and Human Services Public Health Service, Treating Tobacco Use and Dependence, 2003

Summit County Tobacco Prevention Coalition

Current as of January 2008
Internet Citation: 36.94 Physician Pharmacologic Guidelines: Diabetes Planned Visit Notebook. January 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/diabnotebk/diabnotebk3694.html