QuitNow Stop Smoking Medication Guide. Quitting Resources

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1 QuitNow Stop Smoking Medication Guide Quitting Resources

2 QUITNOW STOP SMOKING MEDICATION GUIDE Table of Contents page Intro 2 The B.C. Smoking Cessation Program 2 Nicotine Patches 3 5 Nicotine Gum 6 7 Nicotine Lozenge 8 10 Nicotine Inhaler Nicotine Mouth Spray Bupropion Sr (Zyban ) Varenicline (Champix )

3 Introduction This Medication Guide provides detailed information about various stop smoking aids that are approved for use in Canada to assist you with quitting smoking. While it is normal to experience withdrawal symptoms and cravings during the quit process, medications can significantly reduce the intensity of those symptoms and can double and even triple your chances of quit success. Note: This Medication Guide is for information purposes only and is not a substitute for the advice of a doctor or pharmacist. Medications Covered by the BC Smoking Cessation Program In BC, the government s Smoking Cessation Program helps you quit smoking by helping you with the cost of smoking cessation aids. Prescription stop smoking medications are covered as benefits under PharmaCare. Non-prescription nicotine replacement therapy products (i.e. patches and gum) are provided FREE to BC residents. Products covered under the Smoking Cessation Program include: 1) Two non- prescription (over- the- counter) Nicotine Replacement Therapy (NRT) products: a. nicotine gum (Thrive ); OR b. nicotine patch (Habitrol ) 2) Two prescription drugs: (See your doctor for prescription) a. bupropion (brand name Zyban ); OR b. varenicline (brand name Champix ) To learn more about how to access FREE or subsidized smoking cessation medications, visit the B.C. Smoking Cessation Program website. Stop smoking aids NOT covered by the B.C. Smoking Cessation Program include: 1. Nicotine lozenge 2. Nicotine inhaler 3. Nicotine mouth spray While you may be tempted to opt for the medication that is covered by the B.C. Smoking Cessation Program, you may first want to discuss your options with your doctor or pharmacist to determine what is the best choice for you. 2

4 NICOTINE PATCHES: HABITROL This section describes the Habitrol patch (7mg/14mg/21mg), the only brand covered under the B.C. Smoking Cessation Program. The patch only contains nicotine and none of the other toxins that are in tobacco smoke. The patch sticks to your skin like a bandage, providing a slow and steady release of nicotine into your system to help reduce withdrawal and cravings. Stop smoking completely before you start using the patches. For information on quitting smoking, check out our Guide to Quitting. Advantages of using the Habitrol patch: Easiest to use of the available NRT products. Useful for heavier smokers who need steady release of nicotine. Designed to temporarily replace some of the nicotine that cigarettes would normally supply and thus reduce the symptoms of nicotine withdrawal such as cravings, irritability and anxiety. You can choose the strength of the dosage. This is dependent on the number of cigarettes you smoke per day. See below for suggested dosages or talk to your doctor or pharmacist about dosage. Warnings & Precautions: Do not use if you have severe eczema, psoriasis or other generalized skin disorders. Consult your pharmacist or physician prior to using the patch if the following apply to you: pregnant or breastfeeding being treated for any serious heart condition heart attack or stroke within the last 2 weeks require kidney dialysis use any prescribed medication regularly. Smoking alters the effects of some medications, and when you quit smoking it may be necessary for your doctor to adjust the doses, especially if you are diabetic, taking medications for high blood pressure or heart disease, or taking antidepressants, tranquilizers or sleeping pills. Stop using the patch immediately and see your doctor if you have: chest pain irregular heartbeat 3

5 palpitations leg pain persistent stomach pain rash or hives How to use the Habitrol patch: Dosing Dosing should be individualized based on how much you smoke. To choose which dosage of the patch is right for you, talk to your doctor or pharmacist, or refer to the product monographs and suggested dosing below. The Habitrol patch should be applied and left on the skin for 24 hours per day. Other patch products may be different. Habitrol comes in three patch sizes, which give doses of 21 mg/day (Step 1), 14 mg/day (Step 2) and 7 mg/day (Step 3). Typically a pack- a- day smoker would wear each size for 3 to 4 weeks, gradually reducing nicotine delivery by going from Step 1 to Step 2 to Step 3. Suggested starting doses: # of cigarettes per day First Month Weeks 1-4 Month 2 Weeks 5-8 Month 3 Weeks 9-12 Dose of Patch Dose of Patch More than or fewer Start with Step 1 (21 mg) Start with Step 2 (14 mg) May choose to continue or step down to lower strength (Step 2: 14 mg) May choose to continue or step down to lower strength (Step 3: 7 mg) May choose to continue, step down to lowest strength (Step 3: 7 mg) or stop using the patch completely. May choose to continue or stop using the patch completely. How to APPLY the Habitrol Patch Open the patch wrapper immediately prior to usage, as it will lose the nicotine contained if opened well before use. If applicable, remove the old patch prior to putting on the new one and safely discard in garbage out of reach from children and pets. Peel the liner off the back of the new patch. Place on a non- hairy, clean, dry area of skin (such as the upper arm, hip, back or shoulder) and free of creams, lotions, oils or powder. Women should avoid placing the patch on their breasts. Press firmly for seconds, especially along the edges. Wash your hands after applying. 4

6 The patch should be worn for approximately 24 hours and then removed and discarded. Do not leave it on for more than 24 hours as it may irritate your skin and it loses its strength. Replace your patch at the same time each day to help you to remember to change it. In order to avoid skin irritation, use a different spot for the patch each day. The same area should not be used again for at least one week. What are the common side effects of using the Habitrol patch? headaches cold or flu- like symptoms dizziness anxiety sleep problems vivid or abnormal dreams stomach upset mild itching, burning and tingling are normal in the first hour of wearing the patch redness of the skin when the patch is removed Note: Remove the patch and consult your doctor if you experience chest pain, irregular heartbeat, palpitations, leg pain or persistent stomach upset while using the patch. Things to remember when using the Habitrol patch: Mild itching, burning and tingling are normal in the first hour of wearing the patch. Do not use more than one nicotine patch at a time. Using more than one would increase your risk of experiencing side effects. Do not cut or trim patches. This will interfere with how the nicotine is released from the patch. Only use the nicotine patches as directed. Remove the patch two hours before prolonged strenuous activity or going scuba diving. These activities may increase your risk of experiencing side effects. If you find yourself still craving cigarettes while using the patch, speak with your doctor or pharmacist to see what options (such as using nicotine gum and the patch together) are available for you. But remember that PharmaCare will only cover one smoking cessation aid per calendar year: January 1 st through December 31 st ). 5

7 NICOTINE GUM (THRIVE ) This section describes Thrive gum (2mg/4mg), the only brand of nicotine gum covered under the BC Smoking Cessation Program. Thrive gum is a non- prescription (over- the- counter) nicotine replacement therapy (NRT) product and only contains nicotine and none of the other toxins that are in tobacco smoke. Each piece of gum has nicotine in it, which is released when chewed, allowing you to receive nicotine when you have a craving for a cigarette. For information on quitting smoking, check out our Guide to Quitting. Advantages of using nicotine gum: It s good for occasional smokers to reduce withdrawal symptoms, cravings and manage stress. You can use the gum to help you reduce the number of cigarettes you smoke daily. Warnings and precautions: Stop using the nicotine gum immediately and see your doctor if you have chest pain, irregular heartbeat, palpitations, leg pain or persistent stomach pain. If you have an active jaw disease or jaw/dental pain you should use a different form of NRT, as these conditions will make it difficult to chew the gum. Consult your doctor or pharmacist prior to starting the nicotine gum if the following apply to you: pregnant or breastfeeding being treated for any serious heart condition heart attack or stroke within last 2 weeks require kidney dialysis use any prescribed medication regularly How to use nicotine gum properly: Nicotine gum is available in two strengths (2mg and 4 mg) so choose which is right for you. Nicotine gum shouldn t be chewed like regular chewing gum: Avoid acidic food or beverages like coffee, tea, juice, and soda 15 minutes before using the gum. The acid in these products can prevent your mouth from absorbing the nicotine from the gum. Use bite- park technique. 'Bite' the gum once or twice, then park the gum in the corner of your mouth (between your cheek and gums). Wait one minute, bite the gum a few more times, and then park the gum again. 6

8 Repeat the 'bite' and park process for 30 minutes. It takes 15 to 30 minutes for the gum to start working so use the gum prior to when you think you will need it. For instance, if you used to smoke on your coffee break, take the gum 30 minutes prior to your regular break. What is the appropriate dose of gum to use? Dosing should be individualized depending on your needs and how much you smoke. 2mg gum is recommended for people who smoke 25 cigarettes or less per day 4mg gum is for people who smoke more than 25 cigarettes per day. What is the usual regimen: (Daily maximum: 20 pieces) Note: Discontinue when dose is reduced to 1-2 pieces per day. Possible side effects of using nicotine gum: nausea stomach upset mouth, throat or gum irritation jaw ache hiccups headaches trouble sleeping Reducing the side effects of the gum: Week 1-2 Week 3-4 Month 2 Month 3 # Cigarettes per day Gums/day Gums/day Gums/day Gums/day More than cigarettes cigarettes or less Use the gum correctly. Nicotine gum is not like regular gum. If used incorrectly, you are more likely to experience side effects including dizziness and hiccups Mix the nicotine gum with regular gum to improve the texture (but don't chew like regular gum). Rinse the gum with water after gum use to decrease mouth sores. 7

9 NICOTINE LOZENGE The Nicotine lozenge is NOT covered under the B.C. Smoking Cessation Program. The nicotine lozenge is similar to a cough drop or a sore throat lozenge. It is a non- prescription medication (over- the- counter) available at your local pharmacy. Each lozenge has nicotine in it, which is released when used, allowing you to receive nicotine when you have a craving for a cigarette. For information on quitting smoking, check out our Guide to Quitting. Advantages of using the nicotine lozenge (e.g. Thrive lozenge: 1mg/2mg): Easy to use. Reduces the symptoms of nicotine withdrawal such as cravings, inability to concentrate or irritability. Can be used in combination with the nicotine patch or bupropion to help reduce nicotine withdrawal. You can choose the strength of lozenge to use. This is dependent on the number of cigarettes you smoke per day. Warnings & Precautions: Stop using the lozenge immediately and see your doctor if you have: chest pain irregular heartbeat palpitations leg pain persistent stomach pain Consult your pharmacist or physician prior to using the patch if the following apply to you: pregnant or breastfeeding being treated for any serious heart condition heart attack or stroke within the last 2 weeks require kidney dialysis use any prescribed medication regularly. Smoking alters the effects of some medications, and when you quit smoking it may be necessary for your doctor to adjust the doses, especially if you are diabetic, taking medications for high blood pressure or heart disease, or taking antidepressants, tranquilizers or sleeping pills. 8

10 How to use the nicotine lozenge: Place one lozenge in your mouth and allow it to dissolve slowly. Occasionally move the lozenge from one side of your mouth to the other. Do not chew, swallow or suck on the lozenge as you might with a cough drop. The lozenge should take about 20 to 30 minutes to dissolve. Do not eat or drink during use. What is the appropriate dose of nicotine lozenge to use? There are two strengths of lozenges so talk to your doctor or pharmacist about which strength is right for you. Week 1-2 Week 3-4 Month 2 Month 3 # Cigarettes per day pieces/day pieces/day pieces/day pieces/day More than or less Note: Discontinue when dose is reduced to 1-2 pieces per day. What are the common side effects of using the nicotine lozenge? mouth, throat or tongue irritation nausea stomach upset headaches hiccups taste change Things to remember when using the nicotine lozenge: Don't have any acidic beverages like coffee, tea, juice, and soda while using the lozenge. The acid in these drinks can prevent your mouth from absorbing the nicotine from the lozenge. It is important to carry the lozenges with you at all times so that you can respond to your cravings when they occur. 9

11 FAQs About Nicotine Lozenges How much does the nicotine lozenge cost? A day s supply of nicotine lozenges costs less per day than a pack of cigarettes. Depending on the brand you choose to use the price will vary. Be sure to check with your employer or health plan to see if they pay for all or part of the cost of the lozenge. If the nicotine lozenge is not covered by your employer or health plan, be sure to check the manufacturer website for coupon offers. I have an upset stomach after using a nicotine lozenge, is that normal? Yes. Some people will have an upset stomach from using the nicotine lozenge. This is generally a result of using the nicotine lozenge incorrectly. Sucking, chewing or swallowing the nicotine lozenge may upset your stomach. Can I smoke and use the nicotine lozenge at the same time? Do not smoke or receive nicotine through snuff or other sources at the same time as using nicotine lozenges as you may get too much nicotine and experience side effects. If you are unable to quit smoking after using the nicotine lozenge for two weeks, stop using the nicotine lozenge and then re- start when you are ready to quit smoking again. Can I use both the nicotine lozenge and the nicotine patch? Yes, if you are using the patch and continue to have cravings, it is reasonable to also use nicotine gum, lozenges or inhalers. Speak with your doctor or pharmacist to determine what method is best for you. I have diabetes. Can I use the nicotine gum or lozenges? All nicotine gum and lozenges currently available are sucrose- free. 10

12 NICOTINE INHALER The Nicotine Inhaler is NOT covered under the B.C. Smoking Cessation Program. The inhaler is an option for people who miss the hand- to- mouth ritual of smoking. It is a non- prescription (over- the- counter) nicotine replacement therapy product you can get from your local pharmacy. The inhaler uses cartridges that have nicotine in them, which is released when you puff, allowing you to receive nicotine when you have a craving for a cigarette. For information on quitting smoking, check out our Guide to Quitting. Advantages of using a nicotine inhaler (e.g. Nicorette cartridge delivers 4mg nicotine) It mimics the hand- to- mouth action of smoking. You decide how often to use the inhaler. Reduces the symptoms of nicotine withdrawal cravings and irritability. Warnings & Precautions: Consult your pharmacist or physician prior to using the inhaler if the following apply to you: pregnant or breastfeeding treated for any serious heart condition heart attack or stroke within the last 2 weeks require kidney dialysis use any prescribed medication regularly. Smoking alters the effects of some medications, and when you quit smoking it may be necessary for your doctor to adjust the doses, especially if you are diabetic, taking medications for high blood pressure or heart disease, or taking antidepressants, tranquilizers or sleeping pills. Stop using the inhaler immediately and see your doctor if you have: chest pain irregular heartbeat palpitations leg pain persistent stomach pain Rash or hives How to use the nicotine inhaler Take the mouthpiece out of its plastic wrapper. Line- up the markings on the mouthpiece and separate the two pieces. 11

13 Remove one cartridge from the foil wrapped tray. Press the cartridge firmly down into the bottom of the mouthpiece until the seal breaks. Replace the top of the mouthpiece. Line up the markings. Press the cartridge firmly down to break the upper seal of the cartridge. Twist the mouthpiece to misalign the markings. With the tapered end of the mouthpiece in your mouth, either take in long deep breaths or short puffs. Each cartridge will last for about 20 minutes of continuous frequent puffing. When the cartridge is empty, remove the cartridge from the mouthpiece and dispose of the cartridge out of reach from children and pets. What is the recommended schedule for using the nicotine inhaler? Stop smoking completely before starting the inhaler. Use at least 6 to 12 cartridges per day initially. Do not use more than twelve cartridges a day. As your body adjusts to not smoking, you can choose to stop using the inhaler or slowly reduce the number of cartridges you use a day. Do not use the inhaler for more than six months. What are the common side effects of using the nicotine inhaler? nausea headaches mouth or throat irritation stomach upset Things to remember when using the nicotine inhaler Clean the mouthpiece regularly with soap and water. Don't have any acidic beverages like coffee, tea, juice, and soda while using the inhaler. The acid in these drinks can prevent your mouth from absorbing the nicotine from the inhaler. It is important to carry the inhaler with you at all times so that you can respond to your cravings when they occur. FAQs About Nicotine Inhaler How much does the nicotine inhaler cost? The nicotine inhaler is more expensive that the nicotine patch, gum or lozenge but still costs less per day than a pack of cigarettes. Depending on the brand you choose to use the price will vary. Be sure to check with your employer or health plan to see if they pay for all or part of the cost of the inhaler. If the nicotine inhaler is not covered by your employer or health plan, be sure to check the manufacturer website for coupon offers. 12

14 Can I smoke and use the nicotine inhaler at the same time? Do not smoke or receive nicotine through snuff or other sources at the same time as using nicotine lozenges as you may get too much nicotine and experience side effects. If you are unable to quit smoking after using the nicotine inhaler for two weeks, stop using the nicotine inhaler and then re- start when you are ready to quit smoking again. Can I use both the nicotine inhaler and the nicotine patch? Yes, if you are using the patch and continue to have cravings, it is reasonable to use nicotine gum, lozenges or inhalers in addition. Speak with your doctor or pharmacist to determine what method is best for you. My throat is irritated after using the inhaler. Is that normal? Yes. The nicotine inhaler may irritate your throat. This should decrease as you continue to use the inhaler. If it persists, contact your doctor. 13

15 NICOTINE MOUTH SPRAY The Nicotine lozenge is NOT covered under the B.C. Smoking Cessation Program. The mouth spray provides fast relief from cravings. One to two sprays can control cravings in 60 seconds. It is a non- prescription (over- the- counter) nicotine replacement therapy product you can get from your local pharmacy. For information on quitting smoking, check out our Guide to Quitting. Advantages of the nicotine mouth spray: Control cravings fast. You decide how often to use the mouth spray (i.e., use it only if you need it) Reduces the symptoms of nicotine withdrawal cravings and irritability. Warnings and precautions: Consult your pharmacist or physician prior to using the inhaler if the following apply to you: Pregnant or breastfeeding. Being treated for any serious heart condition. Heart attack or stroke within the last two weeks. Require kidney dialysis. Use any prescribed medication regularly. Smoking alters the effects of some medications, and when you quit smoking it may be necessary for your doctor to adjust the doses, especially if you are diabetic, taking medications for high blood pressure or heart disease, or taking antidepressants, tranquilizers or sleeping pills. Stop using the inhaler immediately and see your doctor if you have: Chest pain. Irregular heartbeat. Palpitations. Leg pain. Persistent stomach pain. Rash or hives. How to use the nicotine mouth spray: Prime the dispenser - point the nozzle away and press the dispenser several times until a fine mist appears. If the spray is not used for 2 or more days, this may be repeated. Hold dispenser as close to the open mouth as possible avoid the lips. Press the top of the dispenser to release one spray into the mouth. 14

16 Do not inhale while spraying spray into the mouth not the throat. For best results, do not swallow for a few seconds after spraying. If after a few minutes cravings are still present, spray once more. Recommended schedule for using the nicotine mouth spray: Stop smoking completely before starting the mouth spray. Use a maximum of 2 sprays at a time, maximum 4 sprays per hour. Do not use more than 64 sprays per day. As your body adjusts to not smoking, you can choose to stop using the mouth spray or slowly reduce the number of sprays you use a day. Do not use the mouth spray for more than six months, unless directed to do so by your healthcare provider. Common side effects: Tingling lips Hiccups Strong taste from nicotine throat irritation nausea heartburn Things to remember: Do not have any acidic beverages like coffee, tea, juice, and soda while using the mouth spray. The acid in these drinks can prevent your mouth from absorbing the nicotine from the mouth spray. It is important to carry the mouth spray with you at all times so that you can respond to your cravings when they occur. FAQ s about the nicotine mouth spray: How much does the nicotine mouth spray cost? The nicotine mouth spray is more expensive than the nicotine patch, gum, or lozenge but still costs less per day than a pack of cigarettes. Each mouth spray cartridge contains 150 sprays of nicotine - replaces up to 150 cigarettes, or 75 for those who require 2 sprays. Be sure to check with your employer or health plan to see if they pay for all or part of the cost of the mouth spray. If the nicotine mouth spray is not covered by your employer or health plan, be sure to check the manufacturer s website for coupon offers. Can I smoke and use the nicotine mouth spray at the same time? Do not smoke or receive nicotine through snuff or other sources at the same time as using nicotine mouth spray as you may get too much nicotine and experience side effects. If you are unable to quit smoking 15

17 after using the nicotine mouth spray for two weeks, stop using the nicotine mouth spray and then re- start when you are ready to quit smoking again. Can I use both the nicotine mouth spray and other nicotine replacement therapies? Yes, if you are using the patch and continue to have cravings, it is reasonable to use nicotine gum, lozenges, inhalers, or mouth spray in addition. Speak with your doctor or pharmacist to determine what method is best for you. My throat is irritated after using the mouth spray. Is that normal? Yes. The nicotine mouth spray may irritate your throat. Try to avoid spraying the mist into your throat, spraying mist under the tongue may help. If the irritation persists, contact your health care provider. 16

18 BUPROPION SR (Zyban ) Bupropion SR (Zyban ) is one of two prescription medications covered under the B.C. Smoking Cessation program. Bupropion is only available by prescription from your doctor. It is a prescription drug that helps people to quit smoking by reducing your cravings for a cigarette and can help alleviate the anxiety associated with nicotine withdrawal. Note: Start taking bupropion two weeks before you quit smoking. Advantages of using bupropion: It is easy to use. It does not contain nicotine, which is important to some people. It can delay weight gain after quitting for some people. It can cause cigarettes to taste bad or not enjoyable for some smokers. It doubles your chances of quitting successfully. Warnings & Precautions: Do not use bupropion if one of the following applies to you: currently using bupropion for another reason have an allergy to bupropion seizure disorder eating disorder, such as anorexia or bulimia heavy alcohol drinker who plans to quit drinking abruptly recently (in the last two weeks) or currently use a class of medications called Monoamine Oxidase Inhibitors (MAO- I) currently using a drug called thioridazine Speak to a doctor or pharmacist about whether bupropion is right for you if one of the following applies to you: liver or kidney problems pregnant or breast- feeding high blood pressure less than 18 years old currently taking medications that can increase your risk of seizures 17

19 How to use bupropion: (Discuss with your doctor) Bupropion is available as a pill that you take by mouth. You will need a prescription from your doctor. Start taking bupropion two weeks before your quit date. Continue to smoke as usual while taking bupropion until your quit date. The recommended dose of bupropion to help you quit smoking is: o o Days 1-3: Take one 150mg tablet once a day in the morning Day 4 to the end of treatment: Take one 150 mg tablet twice a day, once in the morning and once in the early evening (at least 8 hours between doses) The recommended length of bupropion therapy is seven to twelve weeks. You can take bupropion with or without food. What are the common side effects of using bupropion? dry mouth insomnia headache shakiness or nervousness weight loss Stop bupropion and speak to your doctor or healthcare provider immediately if you experience: agitation depressed mood suicidal thoughts or behaviour 18

20 VARENICLINE (Champix ) Varenicline (Champix ) is one of two prescription medications covered under the B.C. Smoking Cessation program. Note: Start taking Varenicline two weeks before you quit smoking. READ HEALTH CANADA ADVSIORY: Health Canada reviewing stop- smoking drug Champix (varenicline tartrate) and potential risk of heart problems in patients with heart disease (June 27, 2011). Varenicline is only available by prescription from your doctor. Varenicline is a drug that helps people to quit smoking by relieving nicotine withdrawal symptoms. Varenicline helps to relieve the nicotine withdrawal symptoms that occur after your quit date. It is also though to work as a weak version of nicotine on the nicotine receptors, but also blocks the effects of nicotine on your brain if you end up smoking while taking varenicline. Taking varenicline doubles or triples your chances of quitting smoking successfully. More people are able to quit on varenicline than bupropion and varenicline may be slightly more effective than NRT. Advantages of taking varenicline: It is easy to use. You simply take a pill once or twice a day. It does not contain nicotine, which some people find important. It doubles or triples your chances of quitting successfully. Do not use varenicline if one of the following applies to you: allergy to varenicline currently using NRT. The combination of taking both does not increase your chance of quitting and increases the likelihood of experiencing side effects. less than 18 years old pregnant Speak to a doctor or pharmacist about whether varenicline is right for you if one of the following applies to you: depression or other mental health problems breast- feeding kidney problems currently taking medications such as insulin, theophylline, or warfarin 19

21 Stop taking varenicline if you experience any of the following symptoms: depressed mood agitation changes in behaviour that are not typical suicidal thoughts or behaviour thoughts of harming yourself or others How to use varenicline Varenicline is available as a pill that you take by mouth. You will need a prescription from your doctor. Start taking varenicline two weeks before you quit smoking. Continue to smoke as usual while taking varenicline until your quit date. The recommended dose of varenicline to help you quit smoking is: o Days 1-3: take one 0.5mg tablet once a day. o Days 4-7: take one 0.5mg tablet twice a day, once in the morning and once at night. o Day 8 to the end of treatment: take one 1mg tablet twice a day, once in the morning and once at night Take varenicline after eating and with a full glass of water. What are the common side effects of using varenicline? Nausea and vomiting Gas and constipation Insomnia and abnormal dreams Headache If experiencing mood and behavioural change, suicidal thoughts report to your doctor immediately. 20

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