TTTF2- Project ECHO Selecting the Optimal Tobacco Cessation Medication Rosario Wippold

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1 TTTF2- Project ECHO Selecting the Optimal Tobacco Cessation Medication Rosario Wippold

2 Selecting the Optimal Tobacco Cessation Medication Review medical/ mental health conditions to have into account when choosing a smoking cessation medication Review interactions between certain psychotropic medications and smoking cessation medications

choosing a smoking cessation medication Review interactions

3 Selecting the Optimal Tobacco Cessation Medication Review the effect of smoking cessation on the metabolism of certain psychotropic and other selected medications

4 MR. XY Pt is 65 y/o male with hx of major depression since his 20s. Pt has had an episode of suicide attempt at age 25 by cutting his wrists. He was hospitalized and has been stable since with medication and on/off psychotherapy. Pt has NIDDM and very poor dentition. Recently he was diagnosed with gallstones and is scheduled to undergo a cholecystectomy next month. Pt smokes 1.5 packs of cigs per day, and he is not very motivated to quit smoking because he feels he will not be able to do it, but he is willing to try.

He was hospitalized and has been stable since with medication and on/off psychotherapy. Pt has NIDDM and very poor dentition.

5 MR. XY Which tobacco cessation medication most likely will be the most beneficial for this patient given his current circumstances?

6 MS. XX Pt is 32 y/o female with hx of bipolar disease and panic attacks since age 18. She has not been adherent to her psychotropic medication regimen or to her scheduled therapy sessions. She has used on and off several psychotropic medications, most recently she has been started on Lamictal (2 months ago) with some success. Paroxetine has been helpful for her panic attacks for the last 2 years. Ms. XX smokes 2 packs of cigs per day and wants to quit smoking but is very anxious about this.

She has used on and off several psychotropic medications, most recently she has been started on Lamictal (2 months ago)

7 MS. XX Which tobacco cessation medication most likely will be the most beneficial for this patient given her current circumstances?

8 Why to Tailor Smoking Cessation Medications Each patient has unique medical, psychological, and social needs The different smoking cessation medications have different mechanisms of action, route of administration, and possible side effects

different smoking cessation medications have different

9 Why to Tailor Smoking Cessation Medications To achieve the best therapeutic effect with the minimal amount possible of side effects

10 Smoking Cessation Medications There are 3 FDA approved smoking cessation medications: Nicotine Replacement therapy (NRTs): Patch, Gum, Lozenges, mini Lozenges, Inhaler, Intranasal Spray

11 Smoking Cessation Medications Varenicline (Chantix) Bupropion (Wellbutrin)

12 Screening Patients to the Use of NRTs When evaluating a patient for the use of NRTs, it is important to consider the following conditions that could make difficult its correct use:

13 Screening Patients to the Use of NRTs Oral/ Nasal NRTs 1. Use of dentures/ teeth extractions 2. Impending Maxillo Facial surgery 3. Mouth Sores

14 Screening Patients to the Use of NRTs Nicotine Transdermal Patch 1. Allergy to Latex products 2. Untreated coronary artery disease (CAD)/Unstable angina 3. Uncontrolled palpitations 4. Sleep disorder

Untreated coronary artery disease (CAD)/Unstable

15 Screening Patients to the Use of Varenicline (Chantix) The following conditions will call for a cautious use of this medication: Age> 60 Decreased creatinine clearance GI problems Sleep disorder Fatigue Pregnancy

cautious use of this medication: Age> 60 Decreased

16 Screening Patients to the Use of Varenicline (Chantix) Unstable depression Current suicidal ideation Other unstable psychiatric problems Allergy to this medication

17 Screening Patients to the Use of Bupropion The following conditions will call for a cautious use of this medication: Increased hepatic enzyme values Brain disease/ Head Trauma (might increase the risk of seizures) Seizures Sleep disorder Anxiety

Increased hepatic enzyme values Brain disease/ Head Trauma

18 Screening Patients to the Use of Bupropion Severe Migraine Headache Hypertension Dry Mouth Unstable psychiatric problems Eating disorders Heavy alcohol use/dependence Pregnancy Past adverse reaction to Bupropion Use of feeding tube

psychiatric problems Eating disorders Heavy alcohol

19 Screening Patients to the Use of Bupropion The use of Bupropion concurrently with the following medications is not recommended or only to be used cautiously: TCA Levodopa Carbimazole Reglan Theophylline

medications is not recommended or only to be used

20 Screening Patients to the Use of Bupropion Concurrent use with the following medications is contraindicated: MAOIS Tamoxifen Linezolid Procarbazine

21 Other Considerations The serum levels of certain psychotropic medications can be affected by smoking cessation by: Increasing serum levels of the medication Increasing the risk of cardiotoxicity

22 Other Considerations Increasing sedation Leading to extrapyramidal side effects (please refer to the provided handout on this topic)

23 Commonly Used Antipsychotics Increasing the Serum Levels After Smoking Cessation Chlorpromazine Clozapine Haloperidol Olanzapine

24 Antipsychotics with No Known Effect in Serum Levels After Smoking Cessation Quetiapine Risperidone Ziprasidone Zotepine

25 Commonly Used Hypnotics and Anxiolytics Increasing the Serum Level After Smoking Cessation Zolpidem Alprazolam

26 Commonly Used Antidepressants and Anxiolytics Increasing the Serum Level After Smoking Cessation Mirtazapine Duloxetine Lithium (possibly)

27 Medications Increasing the Serum Levels After Smoking Cessation That Require Special Attention Methadone Theophylline

28 And Finally, Educate Patients receiving therapy with: Coumadin Insulin Oral Hypoglycemics Patients with high daily intake of caffeine (about possible changes in the metabolism of these medications once tobacco is no longer used)

29 Putting It All Together When selecting a tobacco cessation medication, it is important to keep in mind: Medical history and Mental health history Current Medications Allergies Smoking Alcohol/ drug use history

30 MR. XY Pt is 65 y/o male with hx of major depression since his 20s. Pt has had an episode of suicide attempt at age 25 by cutting his wrists. He was hospitalized and has been stable since with medication and on/off psychotherapy. Pt has NIDDM and very poor dentition. Recently he was diagnosed with gallstones and is scheduled to undergo a cholecystectomy next month. Pt smokes 1.5 packs of cigs per day, and he is not very motivated to quit smoking because he feels he will not be able to do it, but he is willing to try.

31 MS. XX Pt is 32 y/o female with hx of bipolar disease and panic attacks since age 18. She has not been adherent to her psychotropic medication regimen or to her scheduled therapy sessions. She has used on and off several psychotropic medications, most recently she has been started on Lamictal (2 months ago) with some success. Paroxetine has been helpful for her panic attacks for the last 2 years. Ms. XX smokes 2 packs of cigs per day and wants to quit smoking but is very anxious about this.

32 References Hunter New England Area Health Service. Drug Interactions with Smoking. Hunter New England Area Health Service; July Medicines Information Centre, Pharmacy Department, Smoking and Drug Interactions, Mersey Care NHS Trust. June pdf Regents University of California, Rx for Change, Drug Interactions with Tobacco Smoke Sandson, Neil B., M.D., Armstrong, Scott C., M.D., and Cozza, Kelly L., M.D. An Overview of Psychotropic Drug Drug Interactions. Psychosomatics 2005; 46: Madhusoodanan, S., Velama, U., Parmar, J., Goia, D., and Brenner, R. A current review of cytochrome P450 interactions of psychotropic drugs. Ann Clin Psychiatry 2014 May; 26(2): Sussex Partnership. NHS Foundation Trust. Guidance for NHS Grampian Staff on Smoking Cessation and Psychotropic Drug Interactions. Desai, HD, Seabolt J, Jann MW. Smoking in patients receiving psychotropic medications: a pharmacokinetic perspective. CNS Drugs. 2001; 15(6):469 94

Guidance on the use of stop smoking products

Guidance on the use of stop smoking products Ref: Pharm-0000.v6 Status: Ratified Guidance on the use of stop smoking products Page 1 of 15 Approval date Contents 1. Purpose... 4 2. Related documents...