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Nicotine Gum Nicotine

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					    Nicotine Gum

 Nicotine absorbed mucosal membranes
 2mg and 4mg strength
  • Rule of thumb: < 24 cigarettes - 2mg
  • > 24 cigarettes - 4mg
 Each piece is good for 20-30 minutes
 Chew gum until “peppery” taste; “park”
     between gum and cheek until peppery
     taste is gone, repeat process
 Beginners should park on the upper jaw
  Nicotine Gum

Pros:
 Easily imitates individual’s nicotine
   loading pattern
 Nicotine reaches brain 5-10 minutes
 Can be prescribed on regular schedule
   and/or PRN use
 Flexibility of use
  Nicotine Gum
Cons:
 Not user friendly; must follow instructions
 Difficult with dental work & gum chewers
 Makes saliva; GI problems
    Hold gum on upper jaw for first week
    Spit saliva out
    Minimal chewing
 Restrictions with eating and drinking
 OTC, expensive
 Difficulties getting off the gum
Nicotine Patch

  Six dosages: 21mg, 14mg, 7mg or
   15mg, 10mg, 5mg
  Both OTC and prescription
  16-24 hour doses
  Place on non-hairy area above the waist
  Place on a “non-boney” area
  Nicotine Patch Delivery Pattern




              8 - 10 hours   8 - 10 hours


Application
2 hours
       TYPICAL SMOKING PATTERN

Nicotine level
before bedtime




                                 1 -1.5 hours




                 First 2 hours
Nicotine Patch
Pros:
    User friendly: just stick on and go
    Once a day dosing
Cons:
    Dosing issues, Steady-state dosing
    ≈ 2 hrs to reach therapeutic level
    Skin reactions
    Sleep disturbance if worn at night
    Can cause “dull” pain on “boney” areas
    Passive aid
Dosing the Nicotine Patch

For patients who smoke:   Dose
< 5 cigarettes/day        None
5-10 cigarettes/day       14mg/qd
11-20 cigarettes/day      21mg/qd
21-40 cigarettes/day      35mg/qd
> 40 cigarettes/day       42mg/qd
Nicotine Spray

 Nicotine absorbed through nasal mucosa
 1 spray to each nostril after exhale. SHOULD
     NOT BE INHALED
 Each bottle contains 100 doses (200 sprays)
 Not recommended for use more than 5 times
     an hour or 40 times in 24 hours
 Prescription medicine
Nicotine Spray
Pros:
 Quickest absorption (< 5 minutes)
 Prescription-covered by most insurance
   plans
 Flexibility
Cons:
 First week difficult; burning eyes, throat,
   nasal discharge, sneezing
 Poor compliance
 Problems getting off nasal spray
Nicotine Inhaler
 Absorbed through mucosal membranes
 Mouthpiece with 10mg cartridge nicotine
 User “sucks” on mouthpiece to deliver
  nicotine
 3-4 puffs per minute for 5 minutes
  replaces 1 cigarette
 Each cartridge good for 80 puffs or 20
  minutes
 Minimum use: 6 cartridges per day
 Maximum use: 16 cartridges per day
Nicotine Inhaler
  Pros:
   Flexible dosing
   Hand to mouth behavior
   Relatively quick delivery, 5-10 minutes
  Cons:
   Frequent use to achieve adequate
     dosing
   Throat irritation
   Prescription medication, expensive; not
        always covered by insurance plans
Nicotine Lozenge
 Nicotine is absorbed from mucosal
  membranes
 Lozenge dissolves while held between cheek
  and gum
 User must not suck, chew or swallow lozenge
 2mg and 4mg strengths – general rule:
     • < 24 cigarettes use 2mg lozenge
     • >24 cigarettes use 4mg lozenge
 Use up to 20 lozenges per day – no more
  than 5 in one hour
Nicotine Lozenge
  Pros:
   Flexibility of use
   Relatively quick absorption
  Cons:
   Many of same issues as gum
   Chalky buildup at lozenge site
   Hard for people not to chew/suck
   OTC - expensive
Bupropion

 Wellbutrin – antidepressant
 Zyban – smoking cessation aid
 Similar effects on brain as nicotine (60%
  people)
 Prescription required
 Begin treatment 7-10 days before quit date
 3-6 days 150mg; 4th day 150mg bid
 Pregnancy Category B
 Contraindications: seizure disorder, active
  eating disorder, recent MI, unstable angina,
  other antidepressants
Bupropion
Pros:
 Reduces nicotine withdrawal
  • Reduces urge to smoke
  • Quit rates improved: close to 30% abstinence
    at 12 months
 Combination bupropion + NRT’s
  • May be used together
  • 20-30% quit rates NRT or bupropion alone
  • Almost 40% quit rate when combined
    with NRT
Bupropion

Cons:
 Can increase blood pressure
  • Patient with blood pressure issues
      alone
      or with NRT
 Patient sense of discomfort
 Sleep disturbance
 Cost
 Second-line Medications

 Clonidine
   Primary use as antihypertensive
   Research indicates that Clonidine doubles
     the abstinence rates when compared to a
     placebo
   Transdermal or oral delivery
   Side effects – dry mouth, drowsiness,
     dizziness, sedation, constipation
   Can have serious effects if person abruptly
     stops medication
Second-line Medications
 Nortriptyline
   Tricyclic antidepressant
   Increases the rate of abstinence when
    compared to placebo
   Side effects – Sedation, dry mouth,
    blurred vision, urinary retention,
    lightheadedness, shaky hands
   May cause arrhythmias, changes in blood
    flow and contractility – not best for CVD
    patients

				
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