Page 815 - Cardiac Nursing

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C HAPTER 3 4 / Smoking Cessation and Relapse Prevention 791
NRT, bupropion produces cessation rates approximately double constricts coronary arteries and alters hemodynamic profiles,
those of placebo (Table 34-1). leading to increased myocardial workload and oxygen demand.
Unlike NRT, bupropion treatment should be initiated while Cigarette smoking, however, precipitates acute cardiac events
the patient is still smoking, because it takes approximately 1 week by three mechanisms: (1) it produces a hypercoagulable state
of treatment to achieve steady-state blood levels of bupropion. A and promotes thrombosis; (2) it delivers carbon monoxide,
target quit date should be established in the second week of treat- which limits oxygen delivery to the heart; and (3) it alters he-
ment to promote the highest likelihood of cessation. Treatment modynamic profiles. The reviewers also concluded that the al-
with bupropion SR should last a minimum of 7 to 12 weeks and terations in hemodynamic profiles caused by NRT were less
can be maintained up to 6 months. Longer treatment has been hazardous than those produced by cigarette smoking. 25 There-
shown to be effective and should be guided by an evaluation of the fore, it appears that the effects of NRT on the cardiovascular
risks and benefits for the individual patient. system are no greater and are probably less than the effects of
Bupropion is safe and effective for patients with CVD. Ton- cigarette smoking. 26
stad found in a randomized double-blind study of patients with The nicotine patch and gum are the most widely used forms.
CVD that there were adverse heart rate or blood pressure changes The choice of agent is based on patient preference; previous ex-
during treatment with bupropion and that cessation rates were perience (good or bad) with a given form of NRT; whether the
twice that of placebo. 81,82 patient wears dentures, which precludes the use of nicotine gum;
Bupropion is contraindicated, however, in patients at high risk and whether the smoking habit is associated with oral gratifica-
for seizure, previous head trauma, central nervous system tumor, tion, which may favor the gum, lozenge, or inhaler. An alterna-
anorexia nervosa, bulimia, previous seizure, or concomitant use tive form of NRT that has not been widely used is the nicotine
with another medication that lowers the seizure threshold (an- nasal spray. Widespread use may be prohibited by the common
tipsychotics, antidepressants, theophylline, systemic steroids). 79 adverse effects of nicotine nasal spray, including headache, burn-
Bupropion also interferes with the degradation of drugs such as ing sensations in the nose or throat, watery eyes, nasal and
tricyclic antidepressants, -blockers, and antiarrhythmics such as throat irritation, sneezing, runny nose, cough, and sleep distur-
flecainide. 83 Common side effects are insomnia and dry mouth; bances. These adverse effects usually begin on the first day of use
both symptoms are generally transient and usually resolve without but diminish over time. 89 Nicotine nasal spray, however, may be
intervention. 79,82,84,85 Thus, bupropion is generally well tolerated especially helpful for the highly addicted smoker due to its rapid
with discontinuation rates of 6% to 12% because of adverse onset of action. 90 The patch was the most preferred form of
events. 82 NRT followed by the spray, inhaler, and gum. It was noted,
Bupropion has been shown to decrease cravings associated however, that women were more successful at quitting using the
with smoking cessation, which is an important piece of informa- inhaler compared with quitting using the gum, and among those
tion to be aware of when considering pharmacologic interven- heavily addicted smokers the relapse rates to smoking were lower
tions, because craving has been cited as a strong predictor of re- for those using the inhaler than for those using any other form
lapse to smoking cessation. Since craving was cited as the reason of NRT. 91 The use of the nicotine patch and gum, the most
for relapse by 49.2% versus 22.4% of relapsers receiving placebo commonly used forms of NRT are described in more detail in
and bupropion SR, respectively, 86 bupropion has also been Display 34-3.
deemed effective at prolonging the median time to relapse, 156 days Although multiple studies have demonstrated the value of
versus 65 days, when compared to placebo and it has been found NRT in smoking cessation, the use of NRT remains relatively
to delay weight gain when used long-term. 87 limited. Studies continue to document the underuse of NRT
and several theories regarding potential barriers to prescription
Nicotine Replacement Therapy. NRT is a pharmacologic and use have been proposed. For example, the Women’s Initia-
therapy that provides either continuous or bolus dosing of nico- tive for Nonsmoking (WINS) study revealed that of 142 women
tine through the skin (transdermal patch) or mucous membranes with CVD in the intervention group, 127 met the study crite-
(gum, inhaler, nasal spray, lozenge). NRT has been used as a ria for NRT use, but the reported use of NRT by patients
smoking cessation aid since the early 1990s and has consistently ranged from 9% (2-day follow-up) to 22% (90-day follow-up),
demonstrated an abstinence rate of approximately twice that of even in light of the fact that NRT was available to the women
placebo. 62 Combination NRT is also appropriate for those pa- free of charge. The researchers hypothesized that the interven-
tients unable to quit using a single first-line pharmacotherapeutic. tion nurses may have been leery of recommending NRT be-
The meta-analysis performed for the guideline 62 found that com- cause the Agency for Healthcare Policy and Research (AHCPR)
bination NRT therapy doubled the abstinence rate compared had previously cautioned against use of NRT in patients with
with NRT monotherapy. CVD or because of the lack of patient education regarding the
NRT should be used with caution in those patients experi- myths of NRT such as trading one addiction for another. 18 Em-
encing acute cardiovascular events such as recent MI (within mons et al. 92 also demonstrated a low level of use of NRT in
the previous 2 weeks), serious arrhythmias, and unstable angina hospitalized patients; only 7.1% of patients in a sample of 580
pectoris. 61,62 Establishment of a favorable risk-to-benefit ratio male and female smokers who were hospitalized used NRT.
for NRT was based in part on the work of Benowitz, 88 who This finding is consistent with a study of African American
found that blood levels obtained during the use of 2-mg nico- smokers. 93 This study revealed that the major barriers of NRT
tine gum average 12 mg/mL, compared with peak levels with- use were concerns that using it would increase nicotine de-
out the gum of 35 to 54 mg/mL during smoking. 88 Moreover, pendence and concerns about lack of control over drug delivery
in assessing the effects of transdermal nicotine in cardiac pa- and absorption.
tients, multiple studies have found no association between the Another potential explanation for lack of use of NRT is reluc-
patch and acute cardiac events. 61 A review found that NRT tance on the part of health care providers to recognize cigarette