Smoking Cessation: Evidence-Based Approaches and Management Strategies *ACPE-Accredited*

(upbeat music) - Hello everybody, welcome back to the Core Consult RX Podcast. We're coming at you with a fresh episode, hot off of Thanksgiving holiday. Cool, how was your Thanksgiving, man? Did you have a good one? - It was good, certainly gained about two or three pounds, but lost two or three pounds for my wallet, 'cause the shopping that happens. - Yeah, yeah, a lot of cranberries to buy, aren't such. - Yeah, yeah, and the Black Friday stuff and the Cyber Monday stuff. I mean, you tell yourself you're saving money because you're buying all these Christmas gifts or these other things that you've needed throughout the year, but when you just see the charges rack up, it's like, there's no way I'm saving money. - Yeah, I'm not saving that much. - There's no way, there's no possible way. - Do you actually go out on Black Friday and like shop? - No, okay, and my wife did because she had special orders, some sweaters from this particular store that she got them cheaper than like online or whatever. So she had to go to some outlets to get them and it was like a two hour ordeal, 'cause it was crazy. - Yeah, that sounds terrible. - Typically, yeah, there's plenty of stuff online, and you know, everybody says that like I missed the old days when it was just one day when all the sales happened and it's like, you missed the old days where people were getting trampled to death at midnight, at some Walmart, you know? I don't know if I missed those days. - Listen, it's about the love of the game. And that game is getting a brand new 32 inch plasma. 32, yeah, that was big screen back then. - Yeah, so I remember vividly, I must have been 15 probably, but the one like time that I can remember going out like on Black Friday where I actually went out like super early, me and my dad went out and it was because I was trying to get a TV from my room. I saved up money and they had like literally a 32 inch, you know, on sale from whatever it was back then, which would probably be astronomical. - 600 dollars. - Yeah, how cheap they are now. But I remember they like let us in, we ran up, you know, like people literally ran. I was like, oh shoot, like a ruts just like in the movies. How's all pomp, 'cause I was 15. And some like run through target or whatever the heck it was. And got to the TV's, it was like people just, like dive piling on these freaking TV's. I was like, this is, yeah, crazy. And I picked one up and then my dad was, I guess my dad just decided on a win. Like, oh, you know, I'm here, I might as well get one too. And he went to pick one up and some lady like jumped on top of the one he was reaching for, 'cause I was like one of the last ones. And she's like, oh no. And she literally said, I swear, this is not made up. She says, I'll fight you for it. But I just remember looking at my dad and his face, he goes, I think you need it more than I do. Just like gave it to her. I was just like, holy cow, I was just about to fight my dad first. - I mean, dad things would happen. You know, you would wait for the news stories after the Friday night where it's like, you know, such and such fight broke out or such and such persons in the hospital who got trampled and that's come on. - It was like 10% off, dude, like chill. - Yeah, I don't think you needed, you know, that Lego said that, that, that, but yeah, it's crazy. So, you just said that, that like, you know, kind of cured me of me wanting to go out on black Friday. I was just like, ah, this is not worth it. - You know, in hindsight, the people who were fighting, I bet you a lot of them weren't so much just like, mom and pop who wanted to save a few bucks, it was probably scalpers. - 100 bucks, yeah, I'm sure, I'm sure you were like, I'm sure fighters definitely sum out there that we're like, you know, trying to, you know, work with limited funds and like, finally get the forwards of, but I definitely think there's probably a larger than we would assume population out there that's trying to get multiple, you know, items that they can then flip on each other. It's gotta be, yeah. Yeah, I'm sure. But that has nothing to do with what we're talking about tonight and they don't put cigarettes on sale on black Friday. - They sure don't. No, in fact, they've gone nothing but up in price. It's from what patients complain about anyway. And to be honest, I couldn't tell you what, I haven't looked at the price of cigarettes in a while, but they're not cheaper. - Ever since you quit a few years ago? - Yeah, yeah, yeah, yeah, ever since I quit. No, but when I was more motivated back in my younger days, I would just like, "Oh, I gotta, for smoke association, I gotta know everything that there's to know about cigarettes so I used to be familiar with them." But, yeah, kinda let that die with, due to lack of time. But we haven't talked, at least in an accredited fashion about smoking cessation in a while. And our episode with FreeCE, that was previously available for gaining continuing education credit with, is expired now. So we figured we would revisit this topic that hasn't changed a whole lot, but definitely an important topic and something that we run into, regardless of what specialty you work in and smoking cessation is something that always ends up coming up in various patient populations. So I think it's an important one to re-familiarize yourself if you haven't looked at it in a while. So this will be an accredited episode. And you guys, I'm sure, knew how things go at this point. You've heard me say it enough times, but for those of you who are members of FreeCE.com and have access to all of their content, included in that is all of our accredited episodes. And so if you're listening carefully, at some point during this episode, we will give you a password that you will use to access the post-activity test for this particular episode. And that's available on FreeCE's website, FreeCE.com. And past 10 questions, multiple choice quiz tests, whatever you want to call it. And you get one hour of continuing education credit, which is available for pharmacists as well as nurses. And you know, this is a great opportunity to start checking some of your CEO's off if you are needing some to renew your license anytime soon or just trying to get ahead of things. And if you're not a FreeCE member, definitely encourage you, as always, to check out their platform. They have all kinds of different learning opportunities on their different learning styles, whether it's live lectures, podcasts like we're doing tonight. They also have monographs and panel discussions. They have many, I guess, CE's they would call them, where it's like 15-minute segments, or some maybe a little longer, a little shorter, but you can kind of bite-size continuing it as you go. So they have a lot of great information on their platform and definitely encourage you to check them out if you have not already. But we appreciate them, and are thankful that they continue to keep working with us. But that being said, let's jump in to smoking cessation. And we'll cover some background info. And then we'll go through the pharmacotherapy, like always, and wrap it up at the end. Yeah, and we can start with what's happening when you smoke. Yeah, why are cigarettes bad? Why are cigarettes bad? Why are they bad? Why are they addictive? Why do people like them? People like them because they cause direct stimulation of nicotinic acetacolene receptors. And that leads to stimulation of dopamine in the mesolubic pathway, the reward pathway that's going to affect mood elevation. That also can result in appetite, suppression, et cetera, all the things that people experience. But after exposure to nicotine, the nicotinic acetacolene receptors are blocked for a short time. Both nicotine and acetacolene are blocked from binding during that period. There's no stimulation of the mesolubic dopamine receptors during that time. And with chronic use of tobacco, it can lead to excessive upregulation of the nicotinic acetacolene receptors to compensate for that. Dopamine receptors are then downregulated due to excessive dopamine stimulation. And nicotine also not just its effects on dopamine release and all that, but it does have other various physiologic responses as well. So you can get a stimulation of the adrenal glands and epinephrine release. So an overproduction of epinephrine leads to increase heart rate, increase blood pressure. And we know that smoking in general increases, you know, AACVD event or cardiovascular event, pretty significantly. And that's in patients with, you know, whatever comorbidity you may be treating that smoking tends to make things worse in a lot of cases. It also can stimulate glucose release as well as insulin suppression to some extent. So increased frequency of episodes of hyperglycemia, obviously problematic in patients who have diabetes or pre-diabetes, anything that can affect glucose in the wrong ways we would want to ideally stay away from. And it can also lead to frequent fluctuations and dopamine that cause periods of stimulation followed by periods of fatigue, depression like symptoms. And this also is not just because of the negative behavioral health type symptoms, but also tends to lead to more smoking because patients want to not feel that, you know, drop in mood after the nicotine wears off. So they start smoking more frequently. And nicotine tends to increase over time. And obviously, with it being as addictive as it is, this is problematic as well. Right. So that's part of the physiologic addiction. But there's two facets to what people have to battle when they're trying to quit smoking. And that's also kind of the habitual addiction, the things that they're doing when they're smoking that can increase cravings. For example, if you happen to smoke in the car while you're driving, then if you're driving in a car, you might associate it with that. And that's going to increase your risk for cravings. If you take, you know, kind of scheduled smoke breaks during work, then those periods of time during the day can increase cravings if you drink coffee while you smoke as they go in the morning, coffee, increase cravings. All those things that go along with how people go about their day and they're at the habits they form around smoking can increase cravings and cost problems. And you can make recommendations to people about how to avoid those specific activities or to change them up in some way, to mitigate it in some fashion. That's that whole like classical conditioning, you know, which is what Cole's referring to with, you know, the condition stimulus, such as a car or something like that that leads to, you know, craving nicotine because that's when you typically smoke that classical conditioning, you know, on top of the unconditioned stimulus which is that dopamine release is important to kind of dive into with, you know, a patient because each patient's going to have their specific, you know, the either kind of schedule that they keep that, you know, when they have conditioned themselves to want to smoke and all of those factors need to be kind of patient-specific when you're coming up with a treatment plan. It's, you know, pharmacotherapy is great and it can definitely help, but, you know, kind of helping with some of the lifestyle management is just as important. And you know, like Cole said, there's definitely some strategies to kind of work with a patient's particular, you know, conditioned environment that leads to them wanting to smoke. I do feel like cars are a huge one for a lot of patients. I just, whether it's sitting in traffic coming home from work or, you know, whatever it is, I feel like cars in general tend to be a big area of craving for, you know, when it comes to patients who smoke. Yeah, and we went, sorry, go ahead and got our, we went, got our Christmas tree tonight. Yeah. And, you know, I'm pretty cheap. So I just go for the, just the cheapest option. Of course, I guess I could go for a fake tree, but we do real trees. So around the Black Friday weekend lows usually has a discount. So we went to lows for the last day of their discount and got our tree. And typically I would just drive the truck up, you know, toward the tree isn't tossed in the back. And there's this kind of specific lane they have for that. And when the time came, there's just this lady just sitting in her car in the middle of the lane parked with the car on. I guess waiting for somebody just smoking a sig, just hanging out. Just chilling. All right. I guess I'm going to haul this tree half a mile with my car now, because this lady's in the lane, but yeah, smoking is the correlation there. Just knock on the, the window, ma'am, smoking is very bad for you and it's making me have to drag this tree, so now it's even worse. It's now affecting my life, which I don't like. But, you know, the issue with trying to quit smoking is, you know, the, there are definitely withdrawal symptoms, you know, those cravings can be extremely hard to overcome when a patient's first starting to either wean off or, you know, for the patients who try to quit cold turkey. You know, the nicotine withdrawal, it develops, you know, usually within four to 12 hours following that period of smoking, you know, the first, you know, hard stop with, with smoking. And symptom-wise, you know, they can kind of manifest in multiple ways depending on the patient. A lot of times patients are more irritable. They may even be more, you know, aggressive to some extent, increased anxiety, increased restlessness. Patients may feel more fatigued than normal. The increase in appetite is a big factor for patients who have, you know, lost weight or what have you because of smoking. And I knew a patient a while back who had lost like 130 pounds. And when talking to him about how he had lost all that weight, he's like, oh, I started smoking. And it was like very proud of that. And I think we've got better ways now. Yeah, yeah, definitely. Thanks, those are epic. But, you know, the, trying to have that discussion with him of, hey, you know, we do want you to quit because it's not good. It's great. You lost all that weight, but this is probably not the best method of keeping it off. He was just like super, super resisting because he just didn't want to gain the weight back. It wasn't even then he liked smoking so much. It was, you know, just didn't want that increase in appetite. So, you know, the increase in appetite is definitely a factor. Patients, you know, may have more trouble concentrating, you know, that can affect patients with, you know, can come into ADHD or, you know, whatever. And in that regard, depression symptoms, you know, headache, can cause patients to have insomnia, and dizziness. Vertigo, those type of things can occur as well. So, lots of different potential symptoms they can, you know, kind of manifest as a result of that withdrawal period. The manifestations of these, you know, these symptoms are definitely temporary. However, they reach sort of the greatest intensity within the first 24 to 72 hours depending on the patient. And, you know, the symptoms will typically not for everyone, but typically persist, you know, for more than three to four weeks. And it's estimated about at least 40% of patients will still be having some of those withdrawal symptoms at that four week mark. So, it can be a very long and difficult process to wean off of smoking or off of cigarettes. And, you know, I would argue one of the hardest, you know, commonly seen habits that people have to break is very difficult, especially when you start weaving in comorbidities and, you know, behavior of health issues and things like that, that they're sort of self-medicating with, you know, the nicotine with, definitely a difficult thing in which, you know, why they have smoking cessation clinics and, you know, sort of professionals that are dedicated, the majority of their time to this specific topic. Right. And then there, it's good to note that nicotine addiction exists on a spectrum so you can be kind of more or less addicted and a lot of times it's related to how much you smoke and how often and when and there is a kind of a questionnaire or a test called the phagostrom, a test for nicotine dependence. They can help estimate this and things like this can help with the patient's weaning plan and what they use for nicotine replacement. But some of the questions that are asked are, how soon after waking, do you smoke your first cigarette within five minutes, five to 30, 30 to 60 minutes? It gives it a score. Do you find it difficult to refrain from smoking in places where it's forbidden? Like the church or library or anywhere else. I guess these days, it's funny to think when we were kids having the smoking section at a restaurant, you know. - Yeah, that's true. - TGI Fridays or something like that. - Yeah. - If those even exist anymore. And then, you know, your parents are like, I don't want to wait 30 minutes. Let's go sit the smoking section gets. (laughing) It's a nail in it. - Yeah, do you remember those days quite well? - Yes. - Which cigarette would you hate to give up is one question the first in the morning or any other? How many cigarettes a day do you smoke? Do you smoke more frequently in the morning? Do you smoke even if you're sick in bed most of the day? So if you have these have to do specifically with morning, because, you know, that's the longest period of time. A lot of people will go without smoking as from the last one a night to whenever their first one is in the morning. And so it's a good estimation of their physical dependence, I suppose. And when you add up the score, you know, the, if you get a score of one to two, that essentially means low dependence. A score of three to four means low to moderate. Five to seven is moderate. And then eight or more is considered high dependence. And it is interesting that one question you brought up or it says, you know, how many cigarettes do you smoke? If you smoke 10 or less, that actually gives you a score of zero. So it's a lot easier to get someone to quit if they're smoking 10 or less a day, which for those of you who don't know when we talk about, you know, number of cigarettes and what that correlates to nicotine is for most, you know, standard cigarettes. It's essentially one milligram of nicotine. And there's usually 20 cigarettes per pack. So, you know, if you're smoking 10 or less, it's a half pack a day, essentially, or less. So just wanted to throw that out there. I always think that's interesting. For me, thinking about smoking 10 cigarettes in a day, it's crazy. But that's considered a very low amount for people. See, you've got plenty of room to go. Cool. You know, I could do nine and still be technically known to clean it. Yeah, be good to go. Good to go. Just do not smoke within the first hour. You're going to get a point. Yeah, just do everything that this says to do into them, zero, zero, zero, zero, all the way. You're basically using the figure from the samples to beat. To beat the smoke. Yeah. There's some that you can't avoid, no matter what, you're getting one if you want the first question, because it's like, how soon after you wake up, do you smoke for a cigarette? Oh, wait, wait a minute. Actually, the one is 30 to 60 minutes. So I guess if it's after 60 minutes, maybe I get a zero. Yeah. I might get you might get-- You might be able to smoke. You might get smoke a fair amount and still get a zero on the score. Interesting. Yeah. Interesting. You know, we're not encouraging patients to do that, obviously, but just food for thought. Yeah. Don't trick the scores. Yeah, don't trick the scores. Well, they gave me wine and bread. Why not have a cigarette? Yeah, but I will try it. After dinner. Yeah. But you know, the other, like we said, the other factor is not just the fact that the patient has become dependent on a substance, but also all of the other issues that smoking in general causes to the body. It really wreaks havoc throughout the cardiovascular system and several other areas. And patients who have like rheumatoid or other inflammatory conditions that are chronic, it can worsen those type of things. And so, you know, sort of the pathway to getting someone to at least consider quitting is kind of trying to show them the other ways that they can improve other comorbidities and not just telling them smoking is bad. At pretty sure at this point, with the internet and everything else, everyone who smokes is well aware that smoking is not great for your health. But kind of bringing up some of these benefits, as far as their comorbidities and how I can improve their cardiovascular risk and things like that may lead to a little bit more-- if nothing else, interest in the discussion. But some ways to kind of think about it is the first step, obviously, asking the patient about their tobacco use and whether they're a current smoker or a former smoker, but they've never smoked. Because just because someone is a former smoker, they're not actively smoking currently. They could have something that happens in their life that causes a ton of stress or anxiety or depression, whatever, and that triggers a relapse. So that risk still needs to be, you know, at least monitored and the patient's status does need to be kind of an ongoing thing that we check in with because a patient quits doesn't mean that something won't come up. So asking about their current status or current use status, assessing their dependence, which is what that figure strom test was that Cole was kind of going through. And then also assessing what they've used in the past to try and quit if they have. Have they attempted certain medications that didn't work for them, or they had side effects, too. So they went back. What they've been successful with, what they haven't been. And if they've never tried to quit, that's obviously less to work with, but also kind of a clean slate to try different options that we'll be going through here in just a little bit. And then once we've kind of assessed their dependence and prior experience trying to quit and all that, we want to obviously help them to-- not just-- we want to advise them to quit, but then help them come up with a plan and all that. But during that advisory stage, if you will, that's where it would be a good idea to bring up some of the other benefits to quitting and not just giving them an arbitrary. It's better for your health. But given clear examples, we pull up the ACVD risk calculator, show them how much their ACVD risk will go down without smoking, things like that. And then make sure that you offer treatment options. Piss on patients may want to try to do it on their own. And there are definitely behavioral support options and stuff out there. But listing out some of the pharmacotherapy options, I tend to want to lay out all of the options and let the patient give their two cents on which option or multiple options may be a better fit for them than others. And then if they do accept the help and do want to move forward with quitting, making sure that we're following up with them closely to avoid the backslide if they do start to go back to their old ways. And so keeping tabs on the patient every week to hit the most four weeks would be a good idea. And then monitoring their treatment response and any adverse effects and adherence and all that good stuff and then addressing any barriers that come along as we go. But having a systematic way like that of thinking about it, it tends to help avoid them and not need of use smoke, yes, no. And then just no, we really want you to quit and just kind of give this arbitrary thing as we say it 20 times a day to 20 different patients. But definitely good to have sort of a flow of things in your mind to build that rapport and hopefully buy in from the patient. - Yep. And we have, there are seven medications approved for smoking cessation and we'll go through each of them individually. They are chantics, which is verinoclin. Bupropreon SR branded as a side band. And then five nicotine replacement products and different dosage forms, patches, gum, lozenges, inhaler, nasal spray. So we'll start with chantics. It is a, what's considered a partial agonist, antagonist. Verinoclin sits in the nicotine receptor sites, blocking nicotine from binding. So when you smoke while you're taking chantics, it's not going to give you that mesolubic dopamine reward that we talked about before. But it still allows for some release of dopamine. So you're avoiding some of the withdrawal effects. So in effect, it's kind of dampening the euphoria, but you're not having the withdrawal of being totally blocked as if you're not smoking at all. - And if, and because of that antagonism activity, if you do smoke while on it, you're not going to get additional euphoric effects because that receptor is blocked from, you know, nicotine being able to bind to it. So it's a very interesting mechanism of action, I think. - It is, it is. And it has some adverse effects associated with it that are good to be aware of. And they are dose-dependent. So we're a member to titrate the dose when somebody's first starting on it. But nausea is pretty common around 16% of patients report that. And then you may have heard of the sleep disturbances or nightmares or bad dreams or whatever. A similar proportion of patients report that and that could be certainly concerning to patients in a big reason for discontinuation. As well as headache and that kind of thing. But the nausea and the nightmares are kind of what I hear about the most. - And they do make, you know, what they call like a starting pack that has the dose titration built in. So that's a lot of times what we'll go with. And then the continuation pack is just like the maintenance dose. They do sell individual like half milligram and one milligram tablets, you know, that you can buy as well. But a lot of times it's just easier to send in a prescription for the dose titration starting pack to make sure that they follow that dose titration appropriately and don't let nausea get in the way of, you know, a successful, you know, quitting or, you know, quitting process. Some other things to keep in mind with Reneklen. We should encourage patients to take it with a full glass of water and also have some food on their stomach which can help with the GI issues, especially in the nausea. We want to, you know, kind of give some patients the, give patients the reassurance that the adverse effects if assuming they're at least tolerable that they do typically diminish over time. Sorry, coughing so much. Just getting over cold. But patients that are experiencing vivid dreams, like Cole mentioned, a lot of times they're one of two things. They're either pretty pleasant dreams or definitely on the more frightening side. And this is especially problematic if a patient has a history of PTSD. And if a patient is coming back, actually just had this conversation with a patient maybe two weeks ago where they had started Reneklen, it was helping significantly as far as cutting back, but their PTSD nightmares had gotten worse since starting it. And so if that does occur, but the patient does like the results of the drug and how it's allowing them to quit or at least helping to quit, then have them take that second dose 'cause typically the first dose is with breakfast in the morning and then the second dose will be, you know, in the evening, but have them take the second dose around 3 p.m. And by the time they actually get ready to go to bed, the drug is sort of on its downward trajectory as far as plasma concentrations. If you take it with dinner, it's sort of peaking right around the time they go to bed for an average patient to bed done. And so having them back that dose up to 3 p.m., having to take it with a snack if possible, but it can definitely limit the dream side effect or nightmare side effect. And one good thing about Vernecline, well, there's lots of good things, but one additional, especially for pharmacist's good thing is that it's not really metabolized and so the drug interaction risk isn't really there. There's not too many drugs that would cause any issues with Vernecline taking them together. So we don't have, you know, to change medication regiments and things like that very often with somebody starting Vernecline. - In 2009, the FDA requested Pfizer to add a box warning to Vernecline for neuropsychiatric symptoms, including suicidal ideation, move and mood and behavior disturbances and depression. So that has been on there and it's certainly something patients are be aware of. There was a study called the Eagles trial, which was the study evaluating the safety and efficacy of Vernecline and repropriate Breon for smoking cessation that kind of got that added on there and the box warning was removed in 2016, interestingly. - Yeah, after the, I think the Eagles study came out, either in 15 or 16, but then the box warning was removed pretty soon after that. - I got you. - And then there was actually another kind of follow-up study that was put out in the nicotine and tobacco research that was from March of 2021, I'm going to make sure I get the date, right? But the journal article is called Psychiatric Comorbidity and Multi-Morbidity in the Eagles trial, descriptive correlates in association with North psychiatric adverse events, treatment adherence and smoking cessation. And what they were looking for was because patients with psychiatric conditions tend to be more likely to use nicotine as well. They've obviously kind of zoned in on that particular patient population. And a lot of what they found was that even patients with multi-morbidity disease states going on, so like three or more diagnoses, they were still able to use the treatment options available including Veronica and reach a better likelihood of actually reaching that goal of quitting. And so they did note that multiple psychiatric diagnosis does increase the risk of developing the treatment adverse effects in general. It didn't seem to affect the overall benefit that the drugs have. And so the big things, being adherence and whatnot still need to be addressed 'cause those are definitely issues that came up in this study as well. But essentially they were kind of echoing the results of the Eagles trial and showing that we need to be using all of our FDA approved options to help patients to quit. - Now, well, before we do-- - Yeah, nicotine replacement therapy. You want to do the testimony? - It's all the words right on my mouth, which is about to say the same thing. - Yeah, perfect. - Yes, let's do it. So today's password is going to be no smoke. N-O-S-M-O-K-E, all capital letters. No numbers this time. It's like the product, I feel it's the first, one of the first times we've done a password with no numbers. So we're trying to, trying to see if it-- - You bit of clean. - Y'all thought it was going to be similar to something 25, but not today. - Not changing it enough on y'all. So again, make sure if you are a free CE member, use that password to access the post-activity test on freesee.com's website. And you'll get one hour of continuing education credit. So make sure you get that locked in so that you don't wait till the last minute like I tend to do and have all your seas out of the way before renewal time. - Yes, yes. So nicotine replacement therapy as the next thing we'll talk about, and it's certainly a mainstay of smoking cessation therapy. Nicotine replacement comes in a number of dosage forms that I referenced before. The patch is available as 21, 14 and 7 milligrams. The gum is two milligrams and four milligrams. The lozenge also two and four milligrams. There's a prescription nicotine inhaler, the previous options, you can get over the counter. There's a prescription nicotine inhaler with a 10 milligram cartridge, and then there's also a nicotine nasal spray. That's a prescription that is a 10 milligram per ml inhalation, I suppose. - Yeah. And actuation actuation, yeah, there you go. Nice, solid. But using the right terms, but in a lot of times insurance companies will cover these nicotine replacement options. Now they may prefer one over the other and they may want either a certain brand or making sure that it's generic, but the first three that you mentioned that are over the counter, a lot of insurance companies will still cover those even though they are available over the counter. The nicotine inhaler, nasal spray, may be a little bit more difficult to get coverage with. You may require prioritization and things like that, but for patients who would benefit from those options, it's usually something you can get approved, especially if they've tried alternative dosage forms and they weren't successful with them. But we'll start off talking a little bit more about the patches 'cause that can be a really good, if nothing else background sort of nicotine replacement. And this is where the amount that a patient is smoking is very important when it comes to selecting the right starting dose. So if you ever look at like the brand name versions of the patches that Nicoderm CQ, they have step one, step two and step three. Well, if the patient is smoking more than 10 cigarettes a day, so essentially 11 or more, which would be more than a half pack. Number 10 cigarettes or less, half pack or less. So if a patient is smoking 10 cigarettes a day or more, or excuse me, if they're smoking more than 10, so 11 or more, then you do start at the actual step one, which is the 21 milligram patch. You do that usually for weeks one to six. And after that six week period, then the patient can move on to step two, which is the 14 milligram patch. You usually do that for a couple weeks. And then step three is a seven milligram, like Cole said, and that is for another couple weeks. And then they can quit altogether to see how they do. If at baseline the patient is smoking a half pack or less, then you don't want to jump to the, or start them off on step one, that's 21 milligram patch, because most likely it's gonna be more nicotine than their bodies are used to handling. And that's where the nausea and some of those type of side effects are gonna be very noticeable. So if a patient is smoking 10 cigarettes a day or less, start them off at step two with a 14 milligram dose. Do that for the first six weeks and then move on, just like you would to step three after that. But just make sure that you don't just get in a habit of starting every patient off at that 21 milligram dose, 'cause that may be too much for some patients to tolerate. Yes. There are some side effects of the patches to be aware of. Skin irritation, sweating, nausea, vomiting, especially if the patient continues to smoke, which makes sense because you're gonna be getting nicotine through the replacement therapy and then also through the cigarette and that's just gonna increase the risk for nausea. Moody and sleep disturbances, muscle aches. The back hip can be a good spot for placement if the patient is experiencing muscle aches. There's also just a few good counseling points to mention to patients if they're experiencing insomnia or vivid dreams, they should take the patch off before bed because you're giving them a transdermal stimulant throughout the night and it's crossing the blood band barrier and it can cause those effects. You wanna apply the patch to a clean, dry, non-herry area. The Nicoderm CQ is a good choice due to its large adhesive area. You wanna rotate the application site to avoid irritation. Don't cut, open, or chew the patches. Don't apply heat to the patches. That can make it release the medication faster than intended and only wear one patch at a time. - Yes, yes. And those adverse effects, if you notice are all kind of relating to more nicotine than the patient may be used to. So definitely giving them a heads up that while it's not going to necessarily cause any detrimental harm, if they do keep smoking while they're on the patch, like Cole said, it's gonna definitely increase that nausea and worsening side effects for sure. As far as location of where to place the patch, it can go either on the side, like left or right upper arm. It can go on the left or right side of the chest. It can also go on the left or right upper back area or the left or right lower back and it doesn't necessarily matter which the patient prefers as long as they are rotating the site to some extent. They may not have to go to all of those sites each time and they switch it every time they switch the patch but at least make sure they're doing some rotation of site so that skin irritation doesn't occur. - Yes. So the lodges, the lodging is the next one and I mentioned it comes as a four milligram and two milligram lodging. Over the counter and prescription actually, as far as what to dose it or how patients should dose it. If their first cigarette is within 30 minutes of waking, use the four milligram lodging, past 30 minutes. You can use the two milligram lodging. You wanna place it between the gum and the cheek and allow it to dissolve slowly. It's recommended to use one every one to two hours and no more than 20 per day and it has adepers effects like mouth irritation, hiccups, heartburn and nausea. - And you know with the lodging is, they do have some advantages as well as disadvantages but the main advantage is being, the patients can sort of have control of their dose titration and you know, like Cole said, if they're having, you know, breakthrough cravings or something like that, then they can use these kind of on an as needed basis. It's also a good oral substitute for cigarettes, although you know, maybe not as effective for some of that conditional stimulus cravings like the inhaler or something like that maybe that we'll get to in a minute. But nonetheless can be an option and it may be added to the patch to cover situational cravings that pop up the breakthrough cravings. So, you know, just because a patient is prescribed a patch doesn't mean that they can't have an additional, you know, prescription for the lodging or the gum that we're about to talk about. And those can also are often used for those, those breakthrough cravings while the patients, you know, on the patch is sort of like their background, their background release of nicotine. I always think about it as like a basil and perandial insulin, like basil's my sort of background. And then I hit that perandial whenever we need to, you know, get a control of the spike that we get throughout the day. It's completely unrelated, but there's still my dumb brain thinks about it. The other thing that's been official with the lozons, especially as opposed to the gum is that patients can use the lozons even if they have had recent dental work done or they use dentures because the lozons, obviously you're letting just dissolve in the cellular mouth. It's not, you know, something that's gonna affect the dental work or anything. Some, the main disadvantage of the lozons is that you can't have any food or drinks for 15 minutes prior to use or during use. You know, I think that's a disadvantage that most people can live with, but it's still something to at least get patients a heads up about. But then the gum is the next one, also four and two milligrams and it's very similar in how it's used. It's over the counter and prescription less than 30 minutes for the first cigarette. Use the four milligram greater than 30 minutes. Use the two milligram. The recommendation is to chew briefly until the mouth tingles, then park the gum inside the cheek until the tingle fades and then repeat. It's interesting. I'm not sure I could have. I would probably prefer the lozons personally. I feel like I wouldn't have enough control not to just chew the gum. Yeah, I think I would forget all about it within like a couple of minutes. Right, I would just start chewing the gum. And you also have to like be paying attention to when the tingle stops. Yeah. Chew again. But you're supposed to just think about. I know. You're supposed to discard it after 30 minutes. The recommendation is to use one piece per hour with a max of 24 in a day and similar adverse effects of mouth irritation. Also jaw soreness from the chewing hiccups heartburn nausea. Yeah. And some of the advantages again with the gum, same thing with the patient having kind of control over their titration of their dose, that oral substitution for cigarettes. And then it's also like I said, is an added option for patients who are using patches. They can use the gum for as needed use for those situational cravings. Disadvantages the same thing with food or drink, 15 minutes prior to using the gum and then during use, they can't have any food or drink. And then the other disadvantage is if a patient has had any type of dental work done recently, has dentures, then the gum can cause damage to those. And then the whole instructional and education that's required to teach them how to use the gum properly. There's just another potential barrier that can come up based on the patient's willingness to follow the recommended chewing park method. Right. The next is the inhaler, the 10 milligram cartridge. You puff one puff into the mouth or throat until the cravings subside. You don't inhale it into the lungs. You use, which is an important note, you use one cartridge, every one to two hours. Each cartridge contains 80 puffs. So I suppose what is that? I'm just, I can't do the math in my head right now. Less than four. It's okay. If they were to use all of the two milligrams per puff or something. Yeah, something like that. It's low, it's low. It's essentially there to check to kind of help with that hand of mouth sort of habit. I think that's where you tend to see the inhaler being used as patients who it's not even like the nicotine itself that they like. It's literally just having something in their hand. Some patients will switch to snack type food or something like that. I've even seen patients that will cut up little straws and just hold the straw between their two fingers. If it was a cigarette, just because they like having something is that part of the habit is more desirable for them. And the inhaler just allows sort of another method where they can kind of puff on this thing and get a little bit of nicotine, but nowhere near the same extent that a patient would, you know, if they were smoking. Yes. It's 0.125 milligrams per puff. I'm so sad I can't do head and mouth anymore. Too reliant on calculators. So the next is the nasal spray, which is 10 milligrams per ML. It's a 0.5 milligrams per spray and there's 200 sprays per bottle. The recommendation is to use one spray in each nostril, used a needed number of sprays every one to two hours, maximum of 80, adverse effects would be nasal and throat irritation, rhinitis, sneezing, coughing, tearing. This one kind of cracks me up, honestly. 'Cause I do like one puff of flownase and I just hate everything about it. I can taste it in my throat. It just runs out of my nose. I'm doing it correctly, but it just annoys me. That's two puffs. This, there's potentially 80 puffs a day. That's just, it's incredible. That's an incredible amount of puffs to me. I don't think I would choose this. Yeah, that seems like a lot actually. 'Cause that's a lot of puffs. Yeah. But yeah, it's definitely something that I can't say that I've ever seen a patient actually using the nasal spray form, have you? No. Yeah, I've definitely seen, I've even started a patient on the inhaler myself, a couple different patients, but the nasal spray, yeah. I don't, can't think of too many reasons that you would need something like that. Although I will say it is considered to be the most rapid delivery of nicotine among the nicotine replacement products. So that may be partly an advantage to this one over others. And it can still be used in addition to the patch to help with those situational cravings. So maybe if the patient's breakthrough cravings are really intense, then maybe this would be a good option for them, but a lot of patients can't tolerate it because of that local irritation to the nasal mucosa. And it does tend to be more problematic as far as adverse effects compared to the other nicotine replacement products. So definitely not something that is going to be a good fit for every patient, but usually with all of the different formulations or combos of them, you know, you can usually find one, at least one, if not two, that is a good fit for that particular patient that you're treating, right? The other medication that is out there and is widely used is buproprian. The one that is approved for smoking, like Cole had mentioned earlier, is the brand name ZiBan. It's a sustained release formulation, typically used twice a day mechanistically. We are thinking that the buproprian blocks the nicotine receptors in the brain, which then, you know, interferes with that reinforcing effect that nicotine gives. And so you sort of reduce that positive feedback cycle. Buproprian in general was sort of an accidental discovery when it comes to smoking cessation. And it was because we were looking at buproprian to be a treatment option for patients who had schizophrenia. We did note that it didn't actually help with schizophrenia symptoms, but that it was easier for patients who were taking the buproprian to quit smoking. So it was kind of like a sendipitous discovery, if you will, or side benefit to the drug. We typically start off with 150 milligrams once a day for three days, and then increase to one tablet twice daily. We typically encourage patients to start buproprian, one to two weeks prior to their like established or, you know, selected quit date. And then to continue using it for like three to six months, sometimes longer, the way patients describe, you know, the smoking in general, when they're on buproprian, I've heard this from a lot of different patients, but they say that it makes the cigarette taste really gross. I had one patient say it makes her mouth taste like an asterisk. And I don't know if it's up my head, and there may be a reason of how it interacts with taste buds and whatnot, but also, you know, if you're blocking the fork effects that you get from, you know, the nicotine itself, then it may just be, you know, allowing the patient to see what the smoke is without the cloud of that euphoria that sort of masks the nasty side of it. And so the taste and all that and what the smoke is more, you know, noticeable in a bad way. So definitely an option for patients, especially, you know, if they have concomitant depression. And we know that buproprian can cause some weight loss as well to some extent. And so if a patient does have that concern of gaining weight, you know, if they quit, then buproprian may be a good option for them to consider so that you can kind of encourage that their appetite will still be somewhat suppressed and that they won't, you know, gain a bunch of weight back right away. So just some things to consider when, you know, looking at buproprian as a potential option. Right. The SR formulation that's approved and marketed is Zyban. That's the one that's approved. XL and IR are not approved, but it's not really a reason why you wouldn't be able to use those if you need it. If no effect is seen after seven weeks, you can most likely stop treatment. Only about 6 to 20% efficacy was reported in the literature, but it can be a useful additive therapy. And anxious patients, especially if they smoke related to anxiety. And it may lessen post-sociation weight gain while the drug is being taken, because buproprian tends to be weight neutral if not a bit of weight loss. So that could be desirable to some patients. Some adverse effects to make patients aware of, you know, overall, smooth changes potentially can increase insomnia, headache, dry mouth, or poor it as well. And then they can also, buproprian can also lower the seizure threshold. And so if a patient has any risk of seizures, whether that's a history of seizures that may be controlled at this point, but, in fact, that they've had seizures in the past would make them not a good candidate to be on buproprian, or any other condition that's put-- would put them at risk for seizures. You know, if they have any kind of recent head trauma, patients who binge drink, and then because of the potential appetite suppression, if a patient has a history of eating disorders, anorexia, bulimia, things like that, you would also want to use a lot of caution before starting buproprian in those patients. Another one you might see, kind of as a third, four-tough line option, is pammalore, nortriptyline, the tricyclic, antidepressant, which, of course, they block the reuptake of serotonin and norepinephrine, but they also block acetylcholine and histamine receptors. It's not FDA-approved, first-moking cessation. It does have a box warning for increased risk of suicidal thinking and behavior in children, adolescents, and adults, like all antidepressants. And it does have, kind of, overdose risk warning because it can't quickly cause fatal arrhythmias if-- - It takes too high the dose. - They take too much. So, obtain an EKG if there is cardiac risk factors, or if the patient's over 50 years old, but that's mostly related to, you have to overdose. But that does have adverse effects associated orthostasis, anticholinergic effects, vivid dreams, weight gain sedation, sweating, things like that. - And the box warning and the overdose fatal arrhythmias warning, those are more so indicative of a patient who's also using the nortriptyline for depression itself. So, if a patient has no history of depression, it wouldn't be something that I would be overly worried about, but definitely the other anticholinergic effects and all that, the patient needs to be aware of that is a potential. Now, as far as, like, where these sort of fit in first-line, second-line therapy, a lot of times, Veronica is kind of like the go-to first-line option, you know, as long as the patient's willing to start that particular medication or combination nicotine replacement is another good first-line option. So, like, a patch is the base therapy, and then using, like, the lozenger or the gum as needed. And the second-line option would then be propryon or, you know, a single nicotine replacement therapy product if the patient isn't unwilling to use a combo nicotine replacement therapy. And then, third-line would be the nortriptyline, like Cole mentioned, and just because, you know, a patient is already tried Veronica, or, you know, multiple nicotine replacement therapies, we also have the option of using, you know, combined categories as well. So, like, nicotine replacement with, you know, a single agent plus Veronica, you could always use Veronica plus bupropryon, bupropryon plus nicotine replacement therapy. And so, if a patient's, you know, smoking cessation, you know, progress is not improved with monotherapy, or you've tried multiple monotherapy options. The combination of multiple options is definitely something to consider, and I will say there are some clinics who jump right to that, you know, just to try to give the patient as much of a leg up as they can to, you know, the quitting process. So, you know, there's not a set way of following or a set algorithm to follow, and the whole patient's specific, you know, selection of pharmacotherapy is something to be always aware of. And, you know, patient's insurance coverage and all that should also be taken into account. They have a lot of other non-pharmacological support options. You know, they have different group, you know, support sessions that are facilitated by, you know, specialists, and they can use that in addition to to pharmacotherapy, which that can be very helpful. There's also, like, individual support, telephone support. There's, you know, brief phone calls that you can set up for patients, and so whatever options you have available or at your disposal to use, definitely should be offered to the patient, 'cause everyone is, the quitting journey is gonna be a little bit different. And then there's also a lot of other, like, community-based behavioral support resources that are out there. There's things like 1,800 quit now, where you, the patient can get counseling by telephone. And, you know, they can also get potential, like, text messaging support, web coaching support, things like that. There's smokefree.gov. There's several others that are out there. There are, like, web-based support programs. So, again, you know, sort of meeting the patient where they're at and offering as many resources to them as you can so that, you know, they have the most likely chance of success. But, you know, definitely kind of gearing the treatment as a whole to that particular patient is very important in not treating this, like, the cookie cutter approach is definitely something to consider. - Yep. - Are we at an hour already, man? - I think we're at a time already. So, I hope you have fun. - What's that? - Yeah, yeah, I'm gonna have fun. - Time's awesome. - I'm having fun. I get it. I hope you all were having fun too. Hope that was helpful. And if you do have any questions, comments, concerns, shoot us an email. They'll be located in the show notes below. And if you want more lecture style material, you know, with PowerPoint slides and all that kind of thing, check out our patreon.com/coreconsultRx. We have lectures on there that cover the pharmacotherapy and pathophysiology of a whole bunch of different disease states and can be a good review, you know, or a source to review content. They also have, the individual lectures have pad downloadable PowerPoint slidesets that you can have access to as well. Make sure you check that out. And cold, you have anything else for the people before? We say goodbye. - Nothing from my end. - All right, well, thank you all so much for listening. As always, and we will see you all on the next episode. Have a good night.