Transdermal clonidine therapy and nicotine withdrawal by pengxiuhui



                                                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
    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;
    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.
    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-

        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

(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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