Smokers who have been smoking more than 40 cigarettes daily can be safely treated with a high-dose nicotine patch, according to Professor Richard Hurt, professor of medicine and director of nicotine dependence center at Mayo Clinic in Rochester, Minnesota, US.
Current dosing recommendations based on patient’s smoking rate suggest a dose of 7-14 mg/day for those smoking less than 10 cigarettes daily, 14-21 mg/day for those on 10 to 20 cigarettes daily, and 21-42 mg/day for smokers of 21 to 40 cigarettes daily. [Mayo Clin Proc 2000;75:1311-1316]
Hurt said the initial dose can be estimated on the basis of either the patient’s smoking rate or blood cotinine levels, and the adequacy of the nicotine replacement therapy (NRT) can be assessed either by patient response or by the replacement rate of blood cotinine. A higher percentage of blood cotinine replacement may increase patch therapy’s efficacy and improve withdrawal symptoms.
Nicotine gum, patch, lozenge, inhaler, bupropion, varenicline and the combinations thereof can be used as first-line pharmacotherapy, while clonidine and nortriptyline are suitable for second-line. Of these, the patch and varenicline and/or bupropion can be used as “floor” medications, along with short acting NRT products for withdrawal symptoms, said Hurt.
Patient involvement is the key to tobacco cessation and the selection of medicines and their doses should be guided by cardiologists’ clinical skills and knowledge of pharmacotherapy, he added.
One study comparing 24-week extended therapy of transdermal nicotine patch dose of 21 mg/day with 8-week standard therapy showed a dose-response to patch therapy. [Ann Int Med 2010;152:144-151]
In this 568-patient study, smoking abstinence was the same in the two groups by week 8. However, the extended therapy achieved a delayed relapse to smoking.
At week 24, extended therapy produced higher rates of point-prevalence abstinence (31.6 percent v 20.3 percent; [95% CI, 1.23 to 2.66]; P=0.002), prolonged abstinence (41.5 percent v. 26.9 percent; [95%CI, 1.38 to 2.82]; P=0.001), and continuous abstinence (19.2 percent v 12.6 percent; [95% CI, 1.04 to 2.60]; P=0.032) versus standard therapy.
Extended therapy also reduced the risk for lapse (hazard ratio, 0.77 [95% CI, 0.63 to 0.95]; P=0.013) and increased the chances of recovery from lapses (hazard ratio, 1.47 [95% CI, 1.17 to 1.84];P=0.001). At week 52, extended therapy produced higher quit rates for prolonged abstinence only (P=0.027). No differences in side effects and adverse events between groups were found at the extended-treatment assessment.
In a randomized placebo-controlled trial involving varenicline therapy in 714 smokers with stable cardiovascular disease, patch therapy achieved 47 percent abstinence, compared to 14 percent on placebo (95% CI 4.18-8.93). [Circ 2010;121:221-229]
Citing the case study of a 58-year-old smoker with chest pain who was put on two 21mg patches every morning, Hurt said a follow-up phone call 2 weeks later revealed he was experiencing cravings for cigarettes in the evenings, which had increased his use of reliever nicotine inhaler. A 14mg patch at 4pm resolved the issue and the patient was encouraged to use high-dose patches until he could comfortably abstain, and then reduce the morning dose.
“For smokers with coronary heart disease, stopping smoking decreases all cause mortality by 36 percent
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