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79 Case Reports Transdermal Clonidine Therapy weeks from her initial presentation, she is not smoking ciga- rettes but continues to use transdermally delivered clonidine. and Nicotine Withdrawal Case 2 JAMES J. GREEN, MD The patient, a 41-year-old woman, had smoked cigarettes DORIAN H. CORDES, MD, MPH for more than 20 years but quit a year ago with the aid of Tucson nicotine chewing gum. She chews about 20 pieces of gum per CIGARETTE SMOKING is a problem of major medical' and day and has tried unsuccessfully on a number of occasions to economic2 proportions. Addiction to nicotine is extremely cut down but has problems with nervousness, irritability, and difficult to combat, with many treatment methods attempted a failure to concentrate. She had rheumatic fever as a child and variable success rates.3` Clonidine has recently been but has no other significant medical history. On examination shown to reduce nicotine withdrawal symptoms in the early her blood pressure was 148/92 mm of mercury, her pulse was stages of treatment.69 We report the cases of two smokers 66, she weighed 52.3 kg (115 lb), and was 165.1 cm (5 ft 5 treated with transdermal clonidine, both of whom are nico- in) tall. tine-free at 12 weeks oftherapy. This patient was placed on a regimen of 0.2 mg of trans- dermally delivered clonidine and was instructed to taper off Report of Cases of nicotine chewing gum over a two-week period. Her blood Case I pressure dropped to 110/72 mm of mercury during this pe- riod, and she had mild drowsiness and a dry mouth; she was The patient, a 71-year-old woman, presented to the Uni- successful in stopping the gum, however. The clonidine versity of Arizona (Tucson) Smoking Cessation Clinic with a therapy was maintained for an additional two weeks, at history of emphysema and 53 years of cigarette smoking, which time it was stopped. She has been nicotine-free for 12 with an average consumption of 20 cigarettes per day. She weeks at the time ofthis report. had tried to quit smoking on numerous occasions including no less than four organized programs, two of which involved Discussion the use of nicotine chewing gum. Despite these attempts, she Case 1 is a patient who is heavily addicted to nicotine had never quit smoking for more than 24 hours. Problems through cigarettes and for whom treatment in several ap- encountered while trying to quit included nervousness, irrita- proaches has failed. The use of clonidine apparently pro- bility, and an intense craving to smoke. She scored a 7 on the vided some relief of the nicotine withdrawal symptoms that Fagerstrom nicotine tolerance scale, which correlates with a undermined her previous efforts. At 12 weeks of therapy, she high dependence on nicotine. 10 Her current medications in- is a good candidate for placebo patch therapy. The second cluded prednisone, a metaproterenol inhaler, and oxtriphyl- patient is a successful graduate of a nicotine gum program line. Her blood pressure was 100/70 mm of mercury, her who was not able to taper offthe gum. Again, using clonidine pulse was 72, she weighed 48.2 kg (106 lb) and was 162.6 cm appears to have suppressed the withdrawal symptoms suffi- (5 ft 4 in) tall. On examination of her lungs she had decreased ciently to allow a nicotine taper. breath sounds with an increased expiratory phase. This patient was placed on a regimen of a transdermal Smoking cigarettes is a complex psychosocial behavior4 clonidine patch, which delivers 0.1 mg of clonidine per day that has multiple influences. One such influence is the addic- for seven days. She was instructed to taper off her smoking tion to the drug nicotine.3 11 Glassman and colleagues have over the next four days. She was seen again on the seventh shown that the centrally acting ax-agonist clonidine can be useful in the treatment of nicotine withdrawal.6'12 Clonidine day and had stopped smoking two days previously. Her blood in a transdermally delivered form (Catapres-TTS) has also pressure was 90/58 mm of mercury, and she reported being nervous and irritable but felt more comfortable than during been shown to reduce nicotine withdrawal symptoms of any previous attempt to quit, with much less craving to craving, irritability, anxiety, and restlessness when compared smoke. The clonidine patch was replaced weekly for a total with a placebo patch.7 The simplicity of the transdermal of four weeks during which time she did not smoke. During patch makes it especially useful in an office practice.13 The these weekly visits, she was given instructions on stress man- patch comes in three different doses and provides a steady agement and behavior modification. The clonidine therapy release of clonidine over a seven-day period.14 This type of was stopped after four weeks. At five weeks she was again delivery offers the advantages of steady-state blood levels smoking cigarettes, as many as five per day. She was then and increased compliance. I5 The side effects of clonidine use placed on a regimen of 0.2 mg of transdermally delivered are generally mild and include a dry mouth, drowsiness, and a local skin reaction at the site of the patch. 14-16 clonidine, and she stopped smoking within 24 hours. Her Clonidine is a useful adjunct in the treatment of nicotine blood pressure was 90/60 mm of mercury at this time. At 12 addiction, especially in a smoking cessation plan that uses behavior therapy in patients who are motivated and persistent (Green JJ, Cordes DH: Transdermal clonidine therapy and nicotine with- in their attempts at abstinence. 7 drawal. West J Med 1989 Jul; 151:79-80) From the Section of Preventive Medicine, Department of Family and Commu- REFERENCES nity Medicine, Arizona Health Sciences Center, University of Arizona College of 1. Centers for Disease Control: Smoking-attributable mortality and years of Medicine, Tucson. potential life lost-United States, 1984. MMWR 1987; 36:693-697 Reprint requests to Dorian H. Cordes, MD, MPH, Department of Family and 2. Staff Memorandum: Smoking Related Deaths and Financial Costs. Wash- Community Medicine, Arizona Health Sciences Center, Tucson, AZ 85724. ington, DC, Office of Technology Assessment, US Congress, September 1985 80 CASE REPORTS 80CS;EOT 3. The Health Consequences of Smoking: Nicotine Addiction, a report of the Surgeon General. Washington, DC, Dept of Health and Human Services publication ABBREVIATIONS USED IN TEXT No. 88-8406, 1988 4. Smoking cessation: The role of nicotine dependence. Chest 1988; 93 CT = computed tomography (suppl):33S-78S FSH = follicle-stimulating hormone 5. Leventhal H, Cleary PD: The smoking problem: A review of the research and GnRH = gonadotropin-releasing hormone theory in behavioral risk modification. Psychol Bull 1980; 88:370-405 LH = luteinizing hormone 6. Glassman AH, Stetner F, Walsh BT, et al: Heavy smokers, smoking cessa- tion, and clonidine: Results of a double-blind, randomized trial. JAMA 1988; 259:2863-2866 7. Ornish SA, Zisook S, McAdams L: Effects of transdermal clonidine treat- Report of a Case ment on withdrawal symptoms associated with smoking cessation: A randomized The patient, a 49-year-old man, was referred to our controlled trial. Arch Intern Med 1988; 148:2027-2031 8. Wei H, Young D: Effect of clonidine on cigarette cessation and in the allevia- center for a workup for osteoporosis. The diagnosis had been tion of withdrawal symptoms. BrJ Addict 1988; 83:1221-1226 made when he was seen for back pain incurred while 9. Appel D: Clonidine helps cigarette smokers stop smoking. Am Rev Respir Dis 1987; 135:354 swinging a baseball bat. On the initial evaluation he had had 10. Fagerstrom KO: Measuring degree of physical dependence to tobacco tenderness and a decreased range of motion of the thoracic smoking with reference to individualization of treatment. Addict Behav 1978; spine without any previous history of skeletal difficulties. 3:235-241 11. Diagnostic and Statistical Manual of Mental Disorders, 3rd Ed, revised. Plain spine films had revealed a T-4 compression fracture Washington, DC, American Psychiatric Association, 1987 with anterior wedging as well as general deossification ofthe 12. Glassman AH, Jackson WK, Walsh BT, et al: Cigarette craving, smoking withdrawal, and clonidine. Science 1984; 226:864-866 thoracic vertebrae (Figure 1). On quantitative computed to- 13. Green JJ: Smoking cessation and transdermal clonidine (Letter). JAMA mography (CT), the mean spinal bone density was 54.9 mg 1988; 260:1552-1553 per cm3 compared with an age-adjusted normal value of 14. Hollifield J: Clinical acceptability of transdermal clonidine: A large-scale evaluation by practitioners. Am Heart J 1986; 112:900-906 145.5 mg per cm3 . 15. Weber MA, Dryer JI: Clinical experience with rate controlled delivery of The patient's history included a lifelong, large dietary antihypertensive therapy by a transdermal system. Am Heart J 1984; 108:231-236 16. Weber MA, Dryer JI, McMahon FG, et al: Transdermal administration of intake of milk products and no use of alcohol or tobacco. He clonidine for treatment of high blood pressure. Arch Intern Med 1984; 144:1211- said he had not had previous surgical procedures and did not 1213 have gastrointestinal disorders, a change in stool habits, 17. Kottke TE, Battista RN, DeFriese GH, et al: Attributes of successful smoking cessation interventions in medical practice: A meta-analysis of 39 con- weight loss, or other systemic symptoms. He admitted to trolled trials. JAMA 1988; 259:2882-2889 ceasing all sexual activity in his marriage some 10 years earlier by mutual consent with his wife, but he did note occasional nocturnal penile tumescence and had fathered Prolactinoma in a three children some 15 years earlier. He was taking a daily calcium supplement that he had personally begun a year ear- Middle-Aged Man With an lier as part of a general health maintenance program. Osteoporotic Fracture On physical examination he had normal trunk and ex- STEVEN D. TAYLOR, MD THOMAS M. KELLY, MD Salt Lake City OSTEOPOROSIS OCCURS IN MEN only a sixth as often as in women.1 Various factors contribute to this sex discrepancy, including the longer life expectancy of women, an increased peak bone mass in men as compared with women,2 and the absence in men of a distinct time comparable to menopause when levels of circulating sex steroids decline rapidly and loss of bone is accelerated.3 For both sexes, many factors have been implicated in the etiology of osteoporosis. A de- creased intake or absorption of calcium and vitamin D, im- mobilization, the use of anticonvulsant medications, ethanol ingestion, tobacco use, and various hormonal deficiency and excess syndromes all can cause or contribute to a loss of balance between bone formation and dissolution.14 Except in the extremely elderly, when osteoporosis is found in men, all these factors must be considered before assuming a diag- nosis of idiopathic disease. Such an approach to a middle- aged man who was seen because of back pain and evidence of spinal osteoporosis led to the finding of a prolactin-secreting macroadenoma of the pituitary that had caused secondary hypogonadism. (Taylor SD, Kelly TM: Prolactinoma in a middle-aged man with an osteopo- rotic fracture. West J Med 1989 Jul; 151:80-82) From the Division of General Internal Medicine, Department of Medicine, LDS Hospital and the University of Utah School of Medicine, Salt Lake City. Figure 1.-A portion of a thoracic spine film shows a compression Reprint requests to Thomas M. Kelly, MD, Outpatient Clinic, LDS Hospital, 8th fracture, anterior vertebral wedging, and generalized demineraliza- Ave and C St, Salt Lake City, UT 84143. tion of the vertebrae.
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