efficacy of combination first line agents for smoking cessation sneha baxi, pharm.d. pharmacy...
DESCRIPTION
Statistics 440,000 American lives/year claimed by smoking related diseases $97.2 billion/year spent in health care costs and lost productivity 87% of lung cancer cases are directly related to smoking 80% of emphysema and chronic bronchitis cases related to smokingTRANSCRIPT
Efficacy of Combination First Line Agents for Smoking Cessation
Sneha Baxi, Pharm.D.Pharmacy Practice Resident
University of Illinois at Chicago
Session OutlineDiscuss effects of nicotine dependenceReview smoking cessation methodsPresent research project and resultsConclusionQuestions
Statistics 440,000 American lives/year claimed by smoking related diseases$97.2 billion/year spent in health care costs and lost productivity87% of lung cancer cases are directly related to smoking80% of emphysema and chronic bronchitis cases related to smoking
http://www.lungusa.org/
Deaths Attributed to Cigarette Smoking
http://www.lungusa.org/
Addiction Potential
http://www.cdc.gov/tobacco/nicadd.htm
Cessation MethodsColdTurkey/SelfHelpCounseling/Behavioral
NRT
Bupropion
Otherhttp://www.ahrq.gov/clinic/tobacco/
Smoking Cessation Therapy
First Line Behavioral Modification Nicotine Replacement Therapy
Gum Inhaler Nasal spray Patch Lozenge
Bupropion sustained-release (SR)Second Line Nortriptyline, clonidine
Monotherapy
http://www.cdc.gov/search.do?action=search&queryText=smoking+cessation+therapy+and+quit+rate
Combination TherapyCombinations studiedNicotine patch and gumNicotine patch and nasal sprayNicotine patch and bupropion SRNicotine patch and inhaler
Combination Therapy Abstinence Rates (6 months)
Combination Used Combination (%)
Monotherapy(%)
Patch & gum 27.5 15.3
Patch & gum 27.3 20.7Patch & nasal spray
31.4 16
Patch & inhaler 12.5 11.3Patch & bupropion 38.8 21.3 / 34.8
Variables Associated with Abstinence
Variables associated with higher abstinence rates High motivation and confidence Ready to change Strong support system
Variables associated with lower abstinence rates High nicotine dependence History of psychiatric co-morbidity High stress level
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.table.8634Table
10. Variables associated with higher or lower abstinence rates
University of IllinoisSmoking Cessation ClinicPharmacist managedIndividual appointmentsReferred by other medical practitioners
Initial Visit:Patient Interview
Medical problem listMedication list and allergiesSocial history identifying other current or past addictions, alcohol use, and occupationInsurance
Smoking HistoryReasons why the smoker wants to quitPrevious quit attempts including length of success, time of last attempt, method used, and efficacy of methodBarriers to stopping smokingMotivation and confidence to quit smokingStage of change (pre-contemplation, contemplation, preparation, action, and maintenance)Smoking triggers
Smoking History (cont.)Objective dataFagerstrom score Carbon monoxide readingBlood pressure, PulseWeight
Assessment/PlanBehavioral recommendations Tally sheet to identify triggers Written trigger plan Stress and time management Healthy diet Educational smoking cessation book
Medication recommendations and educationFollow-up scheduled
MedicationAdvantages and disadvantages of each medicationProper use, side effects, expectations, and cost of each medicationDemonstration of each medicationMedication education sheet(s)Prescription
Research Project
ObjectivesPrimary: Assess the efficacy of using combination therapy for smoking cessationSecondary: Identify specific patient populations that may benefit from combination therapy
Study DesignResearch conducted at the University of Illinois Medical CenterIRB approvedRetrospective chart reviewGemini notesAccess data base
MethodsRetrospective chart reviewEvaluate:Demographic dataMedical, medication, and smoking historyMotivation to quitTreatment Outcomes of therapy
CriteriaInclusion Subjects seen at the
UIC Smoking Cessation clinic from January 2000-November 2004
Exclusion Minors (age < 18)
Clinic Demographics: Age (n = 144)
0
10
20
30
40
50
20-29 30-39 40-49 50-59 60-69 > 70
# of
pa
tient
s
Age
Clinic Demographics: Race
AACaucasianHispanicIndianOther
Clinic Demographics: Gender
WomenMen
Patient Characteristics: Smoking History
0
5
10
15
20
25
Number of Subjects
Pack Year History
<10
10-19
20-29
30-39
40-49
50-59
>60
Patient Characteristics: Fagerstrom Score
05
101520253035404550
Fagerstorm Score
0 to 45 to 78 to 10
Patient Characteristics:Co-Morbid Conditions
Medical Condition % Positive (n)
Diabetes Mellitus 20.4 (29)
COPD 10.6 (15)
Psychiatric 25.3 (36)
CAD 10.6 (15)
Seizures 11.3 (16)
Other Addictions 10.6 (15)
Subjects Abstinent > 6 Months: Demographics
Characteristic Monotherapy(n = 12)
Combination(n = 9)
Age (mean)Race (% AA)Sex (% female)
54.866.6 (n = 8)66.6 (n = 8)
47.755.5 (n = 5)77.7 (n = 7)
Co-Morbidities (%) DM COPD Psych CAD Seizures Addictions
2533.325816.60
44.422.233.3022.211.1
Subjects Abstinent > 6 Months: Smoking History
Characteristic Monotherapy(n = 12)
Combination(n = 9)
Pack Year History (mean)
33.7 34.3
Fagerstorm Score (mean)
3.12 4.3
Baseline CO Reading (mean)
13 12.3
MonotherapyMethod # Subjects
(n=120)6 Month Success
Rate % (n=12)
Cold Turkey 90 3.3 (3)
Patch 10 40 (4)
Gum 2 50 (1)
Nasal Inhaler 5 0
Nasal Spray 2 50 (1)Lozenges 3 33.3 (1)
Bupropion 8 25 (2)
Combination TherapyMethod # Subjects
(n= 24)6 Month Success
Rate % (n=9)
Patch + Inhaler 12 33.3 (4)
Patch + Gum 4 25 (1)
Patch + Spray 1 100 (1)
Patch + Bupropion 2 0 (0)
Inhaler + Bupropion 4 50 (2)
Inhaler + Gum 1 100 (1)
ConclusionsHigher percentage of patients were able to quit for at least 6 months in the combination therapy group versus the monotherapy groupSmoking tobacco quit rate similar to national averages
LimitationsLow number of subjects in studyRetrospective studyNo randomization
QUESTIONS?