Primary Care Stop Smoking Pharmacotherapy …

1 Primary care Stop Smoking Pharmacotherapy prescribing summary 1 This summary is taken from the BNF edition 65. It is the prescribers responsibility to ensure that prescribed medicines are safe and appropriate for their patients. Prescribers should refer to the current BNF for further guidance and information on drug contra-indication, and interactions. Nicotine replacement therapy (NRT) as referred to in this summary is prescribed to be used in place of cigarettes after usually planned but abrupt cessation of Smoking .

2 The choice of nicotine replacement preparation depends largely on patient preference and suitability, and should take into account what preparations, if any, have been tried before. Patients with a high level of nicotine dependence, or who have failed with nicotine replacement therapy previously, may benefit from using a combination of an immediate-release preparation and patches to achieve abstinence. Nicotine patches are a prolonged-release formulation and are applied for 16 hours (with the patch removed overnight) or for 24 hours.

3 If patients experience strong cravings for cigarettes on waking, a 24-hour patch may be more suitable. Immediate-release nicotine preparations (gum, lozenges, sublingual tablets, inhalator, nasal spray, and oral spray) are used whenever the urge to smoke occurs or to prevent cravings. Pregnancy, ideally, pregnant women should stop Smoking without using NRT but, if this is not possible, NRT may be recommended to assist a quit attempt as it is considered that the risk to the foetus of continued Smoking by the mother outweighs any potential adverse effects of NRT.

4 The decision to use NRT should be made following a risk-benefit assessment as early in pregnancy as possible. The aim should be to discontinue NRT use after 2-3 months. Intermittent forms of NRT are preferable during pregnancy although a patch may be appropriate if nausea and/or vomiting are a problem. If patches are used, they should be removed before going to bed at night. Dosage form Level of Nicotine Dependency Generic product Dosage instructions Patches Smoking with 10 minutes of waking use (24 hour patch)

5 High Dependency More than 10 cigarettes a day start with High strength patches and step down Lower Dependency Less than 10 cigarettes a day Start with medium strength and step down High strength Nicotine transdermal patches 21 mg/24 hours patch Prescribe starting strength in 14 day intervals for 6-8weeks, and then reduce to each of the subsequent lower strengths (in 14 day intervals) for 2 weeks each. Medium strength Nicotine transdermal patches 14 mg/24 hours patch Low strength Nicotine transdermal patches 7 mg/24 hours patch Does not smoke within 10 minutes of waking use (16 hour patch)

6 High Dependency More than 10 cigarettes a day start with High strength patches and step down Lower Dependency Less than 10 cigarettes a day Start with medium strength and step down High strength Nicotine transdermal patches 25 mg/16 hours patch Prescribe starting strength in 14 day intervals for 6-8weeks, and then reduce to each of the subsequent lower strengths (in 14 day intervals) for 2 weeks each. Medium strength Nicotine transdermal patches 15 mg/16hours patch Low strength Nicotine transdermal patches 10 mg/16 hours patch patch Primary care Stop Smoking Pharmacotherapy prescribing summary 2 Dosage form Level of Nicotine Dependency Generic product Dosage instructions Sublingual Tablets High Dependency More than 20 cigarettes a day start with Higher dosage, 2 tablets sublingually every hour.

7 Maximum of 40 tablets daily. Nicotine 2mg sublingual tablets sugar free If using sublingual tablets alone:- Initially prescribe 2 weeks supply at maximum dose, 280 Tablets. For subsequent prescriptions ascertain actual daily usage and prescribe appropriate quantity to last 14 days, taking in to account any unused portion of the initial prescription. If using in combination with patches please supply half of the suggested quantity. Lower Dependency Less than 20 cigarettes a day Start with low dosage 1 tablet sublingually every hour.

8 Maximum of 20 doses daily. Increase to 2 tablets at each dose if needed. Maximum 40 tablets daily. Inhalator All levels of dependency Nicotine Inhalation Cartridge with mouthpiece 10mg & 15mg available. Maximum daily doses:- 12 x 10mg cartridges 6 x 15mg cartridges If using inhalator alone:- Initially prescribe 2 weeks supply at maximum dose. 168 x 10mg cartridges 84 x 15mg cartridges For subsequent prescriptions ascertain actual daily usage and prescribe appropriate quantity to last 14 days, taking in to account any unused portion of the initial prescription.

9 Nasal Spray All levels of dependency Nicotine 500micrograms/dose nasal spray 200 dose Maximum daily use 64 doses If using Nasal spray alone:- Initially prescribe 2 weeks supply at maximum dose, 4 inhalators. For subsequent prescriptions review with patient to ascertain actual daily usage and prescribe appropriate quantity to last 14 days, taking in to account any unused portion of the initial prescription. Quickmist All levels of dependency Nicotine 1mg/dose oromucosal spray sugar free 150 dose pack Maximum daily use 64 doses If using Nasal spray alone:- Initially prescribe 2 weeks supply at maximum dose, 5 Quickmist sprays.

10 For subsequent prescriptions review with patient to ascertain actual daily usage and prescribe appropriate quantity to last 14 days, taking in to account any unused portion of the initial prescription. Primary care Stop Smoking Pharmacotherapy prescribing summary 3 Prescription Only Medication Varenicline is recommended, within its licensed indications, as an option for smokers who have expressed a desire to quit Smoking ; it should normally be prescribed only as part of a programme of behavioural support such as SSW.