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Achieving a Tobacco-free Aotearoa Together
An update in
pharmacotherapy for
smoking cessation
Hayden McRobbie
Senior Lecturer, Auckland University of Technology
Senior Clinical Research Fellow, Wolfson Institute of Preventive Medicine, Queen Mary University of London
Consultant, Inspiring Limited
hayden.mcrobbie@inspiringlimited.com
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We’ve come a long way, baby
Behavioural
treatments only
1970’s
Nicotine gum, and then
other NRT’s
1980’s
2000
Bupropion
(Zyban)
Varenicline
(Champix)
2006
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Nicotine Replacement Therapy
• Devices to deliver nicotine into the bloodstream to
reduce motivation to smoke by
– reducing cravings and withdrawal symptoms
– reducing the rewarding effect of smoking
options
patch
gum, inhaler, microtab,
lozenge, pouch
nasal spray, mouth
spray
slowest
absorption
intermediate
absorption
fastest absorption
Used for at least 8 weeks
Silagy C et al (2004). Cochrane Database Syst Rev: CD000146
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NRT is effective
Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2008(1)
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…but is not a magic cure
• Despite its effectiveness people using NRT still
have a < 20% chance of quitting a year
• This may in part be due to
– Incorrect use
– Insufficient use
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Reasons for NRT failure
• Unrealistic expectations
• Incorrect use
• Not used for long enough
• Nicotine is often seen as the dangerous
element in cigarette smoke
• Safety concerns can be a barrier to use
Encouraging compliance is important
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Standard treatment regimens
• For many smokers the standard dosing is
sufficient
• In others different (higher) doses may be
needed
• It is also possible that using NRT only
from the quit day is not an optimal
treatment strategy
Benowitz et al (1998) J Pharmacology & Experimental Therapeutics, 287: 958-962
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Better ways of using NRT
• Pre-treatment
• Continuing NRT after lapse
• Combining NRT products
• Higher NRT dosing
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NRT Pre-treatment
• Using NRT prior to quitting, whilst
‘smoking as normal’
• Meta-analysis of four studies
• Pre-treatment with patches for 2 weeks
(3 studies) or 4 weeks (1 study)
• 6-months abstinence OR=2.2 (CI=1.53.2)
Shiffman and Ferguson (2008) Addiction, 103,
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NRT Pre-treatment
No significant difference
between treatments
Sample Size= 1,100
Bullen et al (2010) Addiction In press
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Continuing NRT after a lapse
• Most people stop using NRT when they
lapse
• However continuing to use NRT patch
might reduce the progression to relapse
– E.g. a study of 35mg patch showed a 5-fold
reduction in the risk of full relapse in those
who had lapsed*
Shiffman S, Scharf DM, Shadel WG, Gwaltney CJ, Dang Q, Paton SM, et al. Analyzing milestones in smoking cessation: illustration in a nicotine patch
trial in adult smokers. J Consult Clin Psychol 2006;74(2):276-85
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Faster Acting NRT
• Existing nicotine replacement
treatments (NRT) deliver nicotine
slowly
• Faster delivery systems may improve
withdrawal relief and abstinence
rates
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Faster acting
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Nicotine Cannon
Cannon
5 cartridges
pierced
Sample Size= 2
McEwen, West, Gaiger (2008) Journal of Smoking Cessation 3(2): 117-123
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NRT: Under-dosing?
• NRT typically provide less than half the nicotine
a smoker receives from their tobacco1
• Even with combination NRT treatment many
smokers do not obtain blood nicotine levels
comparable with their baseline smoking levels
– In a trial of combined nicotine patch and inhalator
blood nicotine levels were only 60% of that achieved
during ad lib smoking2
1.
2.
Johnstone E, Brown K, Saunders C, Roberts K, Drury M, Walton R, et al. Level of nicotine replacement during a quit-smoking attempt. Nicotine Tob Res
2004;6(2):377-9
Bohadana A, Nilsson F, Rasmussen T, Martinet Y. Nicotine inhaler and nicotine patch as a combination therapy for smoking cessation: a randomized,
double-blind, placebo-controlled trial. Arch Intern Med 2000;160(20):3128-34
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Higher nicotine doses
• There are modest data to show that higher
degree of nicotine replacement is associated
with greater quit rates
• More highly dependent smokers are more
likely to quit when they use high dose gum
(4mg) versus lower dose (2mg) gum
– RR=1.85, 95%CI: 1.30-2.501
• Similar results are seen with the lozenge2
1.
2.
Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2008(1)
Shiffman S, Dresler CM, Hajek P, Gilburt SJ, Targett DA, Strahs KR. Efficacy of a nicotine lozenge for smoking cessation. Arch Intern Med
2002;162(11):1267-76
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Combining NRT Products
• 6 trials comparing combination with single
NRT shows advantage of combination use
– RR = 1.35 (95% CI: 1.11-1.63)
Patch - provides
background craving
relief
+
Intermittent dosing
product - for control
of ‘breakthrough
craving’
– Mechanism of Action:
• Higher dose of nicotine
• Better control of urges to smoke
1.
Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2008(1)
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Patch and Nasal Spray
*
*
n=237
*
* Significant difference
Blondal et al. BMJ 1999
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6-month CO -validated 7day point prevalence
abstinence rates
A study of ‘mono’ and ‘combi’
treatment
50
40.1
40
31.8
30
33.5
34.4
33.2
Patch
Bupropion
+ Lozenge
22.2
20
10
0
Placebo Bupropion Lozenge
Patch +
Lozenge
• All active treatments were significantly better than placebo
• Only patch + lozenge was better than monotherapy (p=0.04)
Piper et al. Arch Gen Psychiatry 66 (11) 2009
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Higher Dose Patches
• Studies of higher dose patches have
produced modest results
– Seven studies compared higher dose
patches (e.g. 44mg/24 hours) with standard
doses (21mg/24 hours)
– Overall there was a small increase in longterm quit rates (RR=1.15, 95%CI: 1.01-1.30)
1.
Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2008(1)
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CEASE Study: 15mg vs. 25mg patch
p<0.001
p<0.00
5
Tønnesen P, et al. Eur Resp J 1999; 13:238-246.
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Are higher nicotine doses more
effective?
No significant difference
between active treatments
Hughes et al (1999) Nicotine & Tobacco Research 1: 169-174
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Higher Dose NRT
• Ability to self titrate might be more
important that just higher nicotine
levels
• Faster acting product may be more
important for some people
• Perhaps we do not go high enough
1.
Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2008(1)
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High dose NRT and cigarette
consumption
% reduction in cigarette consumption
Benowitz et al (1998) J Pharmacology & Experimental Therapeutics, 287: 958-962
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Individualised Treatment
• There has traditionally been a ‘one size
fits all’ approach with dosing of NRT
• This is at odds with the disease where
people exhibit varying degrees of
tobacco dependence
• There is very little individualisation of
treatment for tobacco dependence as
there is in the management of other
chronic diseases.
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Mayo Nicotine Dependency Clinic
• Aims for 100% nicotine replacement and uses
doses of NRT that are titrated to the clients’
blood cotinine levels while smoking
– Higher percentage cotinine replacement (achieved with 42mg
patches) has been shown to be associated with higher 8-week
quit rates1
• A recent report from the NDC shows maximum
patch dose of 84mg/day2
– In this report six-month point prevalence abstinence rates are
as high as 59%
1. Dale, Hurt, Offord et al (1995). JAMA 274(17): 1353-8
2. Ebbert, Burke, Hays, Hurt. Combination treatment with varenicline and nicotine replacement therapy. Nicotine Tob Res 2009;11(5):572-6
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Cut down then stop
• Nicotine gum and inhalator now licensed for
use prior to stopping smoking
• For smokers not intending to stop
immediately
• The goal is to reduce cigs-per-day by 50%
over up to 6-months
• Follow this by stopping smoking
McRobbie H, Whittaker R, Bullen C. Using Nicotine Replacement Therapy to Assist in Reducing Cigarette Consumption before
Quitting Another Strategy for Smoking Cessation? Dis Manage Health Outcomes. 2006;14(6):335-340
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NRT assisted reduction in people who
don’t want to quit abruptly
• Systematic review* of seven RCTs involving 2767
smokers not willing or able to stop abruptly
• NRT-assisted reduction results in increased quitting
and reduction compared to placebo
Outcomes
Event Rates
RBI (95% CI)
NNT (CI)
Smoking
abstinence for 6
months
6.8% vs. 3.3%
106% (34-215)
29 (15-90)
Sustained smoking
reduction
6.1% vs. 1.6%
284% (132-535)
23 (12-48)
*Moore D, Aveyard P, Connock M, Wang D, Fry-Smith A, Barton P. Effectiveness and safety of nicotine replacement therapy assisted reduction to stop
smoking: systematic review and meta-analysis. Bmj 2009;338:b1024
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NRT as an alternative to smoking
• New measures to
support those
smokers who are
unwilling or unable
to quit tobacco
A Smokefree Future. A Comprehensive Tobacco Control Strategy for England. Department of Health. February 2010.
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New inhalator indication
• ‘Safer Option to Smoking’ strategy
• Indications for use now include:
– To aid smokers wishing to quit
– To aid smokers to reduce the amount of
cigarettes they smoke prior to quitting
– To assist smokers who are unwilling or
unable to quit smoking by replacing some
cigarettes with the inhalator for a safer
option to smoking
Nicorette® Inhalator SPC
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Bupropion
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Bupropion (Zyban®)
• Atypical antidepressant which acts on dopamine and
noradrenaline pathways and possibly as a nicotinic
antagonist, designed to reduce motivation to smoke by
– reducing cravings and withdrawal symptoms
– reducing the rewarding effect of smoking
Started a week prior to quitting, titrated up to 300mg per day
↓ 150mg per day, if side effects
Used for at least 8 weeks
• Hughes J et al (2004). Cochrane Database Syst Rev: CD000031
• Zyban® (Summary of Product Characteristics). 2009. GlaxoSmithKline, Uxbridge, UK.
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Average percentage
(actual range)
Clinical Efficacy
19%
(4-43%)
10%
(0-22%)
Hughes JR et al. Cochrane Database Syst Rev. 2007;Jan 24(1):CD000031.
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Contraindications
•
•
•
•
•
•
•
•
•
Current or previous seizure disorder
Known CNS tumour
Benzodiazepine or alcohol withdrawal
Eating disorders
Hepatic cirrhosis
Bipolar disease
Taking MAOI’s
Pregnancy or breast feeding
Age <18 years
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Dosage
• 150mg daily for the first 3 days, then 150mg
twice daily from day 4.
• Treatment course: 8 weeks.
• Lower dose to 150mg once daily if elderly or
renal/hepatic impairment.
• Remember can cause drowsiness.
• Set quit day between day 8 and 14.
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Risk factors for seizures - cautions
• Drugs known to lower the seizure threshold:
–
–
–
–
–
–
–
–
Antidepressants
Antipsychotics
Antimalarials
Theophylline
Systemic steroids
Tramadol
Quinolones
Sedating antihistamines
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Cautions - continued
• Alcohol abuse
• History of head trauma
• Hypoglycaemia
– Diet controlled DM – can take full dose
– Well controlled DM with insulin or oral hypoglycaemics –
150 mg once a day
– Poorly controlled DM – should not use Zyban
• Use of stimulants or anorectic products
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Side effects
• Common: (> 1/100)
– Insomnia
– Headache
– Dry mouth
– Rash
• Uncommon: (>1/10,000 & <1/1000)
– Seizure
– Severe allergic reaction
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Information for patients
•
•
•
•
It is not a magic cure!
An antidepressant; explain side-effects.
Start with 1 tablet daily for 1st 6 days.
Warn that it could cause drowsiness, and so
beware operating machinery.
• Then 1 tablet twice a day (8 hrs apart).
• The Quit Date at least 1 week after starting
Zyban.
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Risks associated with Zyban
• Dropouts due to AE’s from studies have been
<10%, even in those with cardiovascular
disease
• Does not lead to dependence
• Minimum cardiovascular effects
• Seizure risk does not exceed that of other
antidepressants in common use
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Is bupropion better than NRT?
• In one study Bupropion was better than 21mg
patch (18% vs 10% at 1-year), in newer studies
not different from gum and patch
• Zyban vs. placebo effects may be marginally
larger than for NRT
• Further comparisons of Zyban and NRT are
needed but overall there seems to be little
difference in efficacy
42
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Combination with NRT
• No evidence to say that chances of success are
improved significantly when using both
• No harm in combing both
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Nortriptyline
• Tricyclic anti-depressant, acting mainly on
noradrenaline pathways, designed to reduce
motivation to smoke by
– reducing cravings and withdrawal symptoms
– reducing the rewarding effect of smokingEvidence
• Evidence
– 6 trials; OR = 2.34 (95% CI: 1.61 – 3.41)
• Contraindications & cautions
– recent myocardial infarction or arrhythmias, severe liver disease or those with bipolar
disorder in a manic phase, pregnancy, breast-feeding, elderly, hepatic impairment,
thyroid disease, phaeochromocytoma, history of mania, psychoses, susceptibility to
angle-closure glaucoma, and a history of urinary retention
Hughes J et al (2004). Cochrane Database Syst Rev: CD000031
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Nortriptyline
• Treatment course
Started a week prior to quitting
75 – 100 mg per day
Used for at least 10 weeks
Hughes, J.R., L.F. Stead, and T. Lancaster, Antidepressants for smoking cessation. Cochrane Database Syst Rev, 2004(4)
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Varenicline
a selective 42 re 42 Receptor
Partial Agonist ceptor partial agonist
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Varenicline (Champix®)
• Nicotinic acetylcholine partial agonist targeting α4β2 receptor
subtype, designed to reduce motivation to smoke by
– reducing cravings and withdrawal symptoms
– reducing the rewarding effect of smoking
options
Titrate up to 2mg per
day
2mg per day,
maintenance therapy
↓ 1mg per day, if side
effects
↓ 1mg per day, if side
effects
12 weeks
+ 12 weeks
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Cahill K et al (2007). Cochrane Database Syst Rev: CD006103
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Mode of Action
NICOTINE
•
Binding of nicotine at the 42 nicotinic
receptor in the VTA is believed to cause
release of dopamine at the nAcc
VARENICLINE
•
Varenicline is a compound with dual
agonist and antagonist activities.
1. Coe JW et al. N Engl J Med 2005;34:121-130.
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Cochrane meta-analysis
– vs. placebo
• Varenicline1:
• Bupropion2:
• NRT3:
Long-term efficacy(>6months)
Risk Ratio (95%CI)
2.33 (1.95 – 2.80)
1.75 (1.58 – 1.94)
1.58 (1.50 – 1.66)
– In head to head clinical trials,
Risk Ratio (95%CI)
– Varenicline vs. bupropion 1.52 (1.22 – 1.88)
– Varenicline vs. NRT1
1.31 (1.01 – 1.71)
1
0.5
1
2
1, 2, 3. Cochrane Database of Systematic Reviews: Cahill et al 2008 for varenicline; Hughes et al 2007 for bupropion; Stead et al 2008 for NRT
3
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Safety and Side-effects
• Only true contraindication is allergy to varenicline
• But not recommended in
– Pregnant/breastfeeding women
– Age < 18
• No drug interactions
• Consider dose reduction in those with moderate renal
impairment
• Side effects
– Nausea (30%) – mostly well tolerated
– Strange dreams, headache, flatulence, and insomnia
– Concerns about mood disturbance
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Dosing instructions
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Champix available on prescription
• THE FINE PRINT (Pre-requisites)
– Short-term therapy as an aid to achieving abstinence in a patient who
has indicated that they are ready to cease smoking AND
– The patient is part of, or is about to enrol in, a comprehensive support
and counselling smoking cessation programme, which includes
prescriber or nurse monitoring AND
– The patient has not used varenicline (funded) in the last 12 months AND
– Varenicline is not to be used in combination with other pharmacological
smoking cessation treatments and the patient has agreed to this AND
– The patient is not pregnant AND
– The patient has tried but failed to quit smoking after at least two
separate trials of nicotine replacement therapy, at least one of which
included the patient receiving comprehensive advice on the optimal use
of nicotine replacement therapy OR
– The patient has tried but failed to quit smoking using bupropion or
nortriptyline
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Varenicline vs. NRT in a UK stop
smoking clinic
• The first 208 patients
on Champix in 2007
compared with the
last 204 on NRT in
2006
• Samples with similar
characteristics
p<0.05
Stapleton JA, Watson L, Spirling LI, Smith R, Milbrandt A, Ratcliffe M, et al. Varenicline in the routine treatment of tobacco dependence: a pre-post comparison with nicotine replacement therapy and an evaluation in
those with mental illness. Addiction 2008;103(1):146-54
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Quit rates in the NHS Stop Smoking
Service: by medication
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Quitline + NRT or varenicline
OR=1.85
(95%CI:1.50-2.29)
OR=1.66
(95%CI:1.23-2.24)
Retrospective study of
smokers calling the
Montana Tobacco
Quitline and using NRT
(n=3697) or varenicline
(n=3116)
Predictors of quitting
at 6 months were:
•Older age
•Receiving more
counseling sessions
Biazzo LL, Froshaug DB, Harwell TS, et al. Characteristics and abstinence outcomes among tobacco quitline enrollees using varenicline or
nicotine replacement therapy. Nicotine Tob Res. Jun In press;12(6):567-573.
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50
Abstinent
Smoking
40
30
20
10
>12
9-12
5-8
2-4
0
<2
• 193 varenicline
users from a GP
database
• Self-reported 7day point
prevalence
abstinence at 6
months was 46.1%
7-day point prevalence 6-month
abstinence rate
Varenicline use in general practice
Weeks of varenicline use
Blak BT, Wilson K, Metcalfe M, Maguire A, Hards M. Evaluation of varenicline as an aid to smoking cessation in UK general practice - a THIN
database study. Curr Med Res Opin. Apr 2010;26(4):861-870.
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Varenicline and CVD
OR: 3.92
(95% CI: 2.55 – 6.03), p < 0.0001
OR: 3.14
(95% CI: 1.93 – 5.11), p < 0.0001
Tashkin et al 2001, Wagener et al 2004
Tashkin et al, CHEST conference, 2009
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Treating smokers with COPD
OR=4.04
(95% CI 2.13-7.67)
Tashkin et al 2001, Wagener et al 2004
Tashkin et al, CHEST conference, 2009
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Varenicline: 1-year quit rates
OR=3.14
(95% CI 1.93-5.11)
OR=4.04
(95% CI 2.13-7.67)
Gonzales D et al. JAMA. Jul 5 2006;296(1):47-55
Rigotti NA, et Circulation. Jan 19 2010;121(2):221-229
Tashkin et al, CHEST conference, 2009
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Maintenance of Abstinence
OPEN-LABEL
Varenicline
12 weeks
Quitters randomized
DOUBLE-BLIND
NONTREATMENT
FOLLOW-UP
Varenicline
Placebo
Week12
Week 24
Week 52
60
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Continuous Abstinence Rates
Weeks 12 - 52
Varenicline: 44%
Placebo: 37%
P=0.02
OR 1.34
% of Patients
Week
1. Tonstad S, et al. JAMA. 2006;296:64-71.
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Extended treatment with Champix
62
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Who should have extended use?
•
•
•
•
•
‘Staggered into abstinence’
Only quit recently
Still occasional lapses
Worried about stopping the tablets
Still struggling with urges and withdrawal
63
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Completing treatment
• Consider weaning off via 1 tablet/day
• Do not prophesise difficulties after coming
off the tablets, but if feasible, arrange to see
patients a week after coming off the tablets
to check their progress.
• The extra visit may provide support over the
possible increase in urges to smoke
64
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Using Champix 4-weeks prior to TQD
Baseline
Visit
Week 1
Phone
Week 2
Week 3
Phone
Visit
+ 24
hrs
+1
week
+2
weeks
+3
weeks
+4
weeks
Visit Phone
Visit
Visit
Visit
Visit
TQD
Varenilcine
Placebo
+ 12
weeks
Phone
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Effect on cigarette consumption
25
Cigarettes per day
20
15
10
5
0
Baseline
Week 1
Week 2
Week 3
Quit Day
Time
varenicline (n=43)
placebo (n=35)
Error bars
represent 95% CI
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Effect on CO
35
Carbon monoxide concentration (ppm)
30
25
20
15
10
5
0
Baseline
Week 3
Quit Date
Time
varenicline (n=47)
placebo (n=39)
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Effect on salivary cotinine
450
Salivary cotinine concentration (ng/ml)
400
350
300
250
200
150
100
50
0
Baseline
Week 3
Quit Date
Time
varenicline (n=47)
placebo (n=41)
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Change in strength of urges to smoke
5
4
Rating (1=much
stronger;
3=same as
before; 5=much 3
weaker)
2
1
Baseline
Week 1
Week 2
Time
varenicline (n=39)
placebo (n=37)
Week 3
Quit Day
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Change in enjoyment of cigarettes
5
4
Rating (1=much
more enjoyable;
3=same as 3
before; 5=much
less enjoyable)
2
1
Baseline
Week 1
Week 2
Time
varenicline (n=35)
placebo (n=36)
Week 3
Quit Day
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Smoking and mental health
Current Mental Illness*
No Mental Illness*
Smokers
Nonsmokers
•28.3% of population has current mental illness*
•Patients with mental illness are heavier smokers
•Estimate that mentally ill consume 44% of cigarettes in US
Lasser K etal. JAMA. 2000;284:2606-2610
*within last month
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Annual Suicide Rate per 100,000
males by Cigarettes Smoked/Day
Smoking and suicide
There is a strong association between heavy smoking and high
suicide rate
60
57
40
29
23
33
26
20
0Never Smokers
Ex-smokers
1-14
15-24
25
Cigarettes/Day
Current Smokers
Doll R et al. BMJ 1994;309:901-911.
72
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Varenicline and Psychiatric Illness
Additional analysis in participants receiving
telephone/web support and varenicline
Swan GE, McClure JB, Jack LM, et al. Behavioral counseling and varenicline treatment for smoking cessation.
Am J Prev Med. May In press;38(5):482-490.
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Varenicline and Psychiatric Illness
• No safety concerns
• Equal number of participants with and without
psychiatric illness reported adverse events
• Smokers with psychiatric illness were more
likely to report
– Tension, depression, anxiety, confusion, nausea,
difficulty concentrating
• However these differences disappeared when
controlling for baseline differences
Swan GE, McClure JB, Jack LM, et al. Behavioral counseling and varenicline treatment for smoking cessation.
Am J Prev Med. May In press;38(5):482-490.
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Psychiatric adverse events
• Pooled analysis from all
varenicline RCTs
• Compared psych. AEs in
varenicline (n=3091) vs.
placebo (n=2005)
• With the exception of
sleep disturbance there
was no evidence that
varenicline increased
psych. AEs
RR=1.02 (95%CI:0.86-1.22)
Tonstad S, Davies S, Flammer M, Russ C, Hughes J. Psychiatric adverse events in randomized, double-blind, placebo-controlled clinical trials of varenicline: a
pooled analysis. Drug Saf. Apr 1 2010;33(4):289-301
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Findings from a General Practice Database
• GPRD includes 500 practices, 3.6 million
patients
• 1. Sept 2006 – 31. May 2008
• Compares suicide rate of smokers on
– NRT (N=63,265)
– Zyban (N=6,422)
– Champix (N=10,973)
• Two suicides, both in the NRT group
Gunnell D, Irvine D, Wise L, Davies C, Martin RM. Varenicline and suicidal behaviour: a cohort study based on data from the General Practice Research
Database. BMJ. 2009;339:b3805
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Incidence of psychiatric events
Outcome
Medicine
Number of
events
Risk (95% CI)
Self Harm
NRT
141/63265
(0.2%)
1.0
Zyban
9/6422 (0.1%)
1.17 (0.59-2.32)
Champix
18/10973 (0.2%)
1.12 (0.67-1.88)
30/63265
(0.05%)
1.0
Zyban
2/6422 (0.03%)
1.20 (0.28-5.12)
Champix
15/10973 (0.1%)
1.43 (0.53-3.85)
NRT
1792/63265 (3%) 1.0
Zyban
160/6422 (2%)
0.91 (0.77-1.07)
Champix
292/10973 (3%)
0.88 (0.77-1.00)
Suicidal thoughts NRT
Started antidepressants
Gunnell D, Irvine D, Wise L, Davies C, Martin RM. Varenicline and suicidal behaviour: a cohort study based on data from the General Practice Research
Database. BMJ. 2009;339:b3805
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Expert opinion
• “Although the risk of potential neuropsychiatric
events is evident through voluntary reporting
systems and reported cases in the literature, multiple
studies and case reports support the use of
varenicline in the mental health population”
• “Cautious treatment initiation, patient education,
and close follow-up, monitoring for mood and
behaviour changes during therapy are
recommended”
Purvis TL, Nelson LA, Mambourg SE. Varenicline use in patients with mental
illness: an update of the evidence. Expert Opin Drug Saf. May 2010;9(3):471-482.
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Watch this space
• There are other things on the horizon
– Nicotine inhalers (nicotine pyruvate)
– Nicotine vaccine
• In the meantime use what we have available
in the best possible way