4. PHARMACOLOGICAL INTERVENTION IN SMOKING CESSATION (05.2020).pdf

PHARMACOLOGICAL INTERVENTION IN SMOKING CESSATION

1. PHARMACOLOGICAL
INTERVENTION IN
SMOKING CESSATION

2. 2
CONTENTS
1. MEDICINE FOR SMOKING CESSATION
2. WHICH ONE TO USE?
3. NICOTINE REPLACEMENT THERAPY
4. NON-NICOTINEBASED PHARMACOTHERAPY
5. COMBINATION THERAPY
6. SMOKING AND DRUG INTERACTION

3. 3
CONTENTS
1. MEDICINE FOR SMOKING CESSATION
2. WHICH ONE TO USE?
3. NICOTINE REPLACEMENT THERAPY
4. NON-NICOTINE BASED PHARMACOTHERAPY
5. COMBINATION THERAPY
6. SMOKING AND DRUG INTERACTION

4. 4
TYPES MEDICINES FOR SMOKING CESSATION TREATMENT
Nicotine Based Non-Nicotine Based
1.Varenicline
2.Bupropion SR
3.Nortriptyline
4.Cytisine
5.Clonidine
6.Anti Nicotine Vaccines
1.Nicotine Gum
2.Nicotine Patch
3.Nicotine Lozenge
4.Nicotine Inhaler
5.Nicotine Nasal Spray

5. 5
CONTENTS
1. MEDICINE FOR SMOKING CESSATION
2. WHICH ONE TO USE?
3. NICOTINE REPLACEMENT THERAPY
4. NON-NICOTINE BASED PHARMACOTHERAPY
5. COMBINATION THERAPY
6. SMOKING AND DRUG INTERACTION

6. 6
COST
EFFICACY
SAFETY
Element TitleSUITABILITY

7. 7
Cochrane Systematic Reviews
Long-term outcomes
Combination NRT and
vareniclineare:
✔equally effective
✔higher quit rates than
single form NRT
(OR =1.57, 95% CI 1.29-1.91)
(Kate Cahill et al 2013)
EFFICACY

8. 8
SUITABILITY
Factors to consider :
1. Current medical condition
2. Nicotine Dependence(FTND Score)
3. Number of Cigarette/day (not a good guide)
4. Patient’s preference
5. Medication adherence issues
6. Previous experience with cessation medications
7. Social factor/ occupational related

9. 9U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 2008
COST-EFFECTIVENESS
OF TOBACCO DEPENDENCE
The tobacco dependence treatments shown to be effective in US
Guideline (both counseling and medication) are HIGHLY COST-
EFFECTIVE relative to other reimbursed treatments and should be
provided to all smokers. (Strength of Evidence = A)

10. 10
CONTENTS
1. MEDICINE FOR SMOKING CESSATION
2. WHICH ONE TO USE?
3. NICOTINE REPLACEMENT THERAPY
4. NON-NICOTINE BASED PHARMACOTHERAPY
5. COMBINATION THERAPY
6. SMOKING AND DRUG INTERACTION

11. 11
TYPE OF NRT PRODUCTS
INMOH Drug Formulary NOTin MOH Drug Formulary
Nicotine
Gum
Nicotine
Patch
Nicotine
Inhaler
Nicotine
Lozenges
⮚Group C
poison
List A/KK

12. 12
MECHANISM OF ACTION
NICOTINE REPLACEMENT THERAPY
NRTmedicationsdeliver
nicotinewiththeintentto
replacethenicotine
obtainedfromcigarettes
andtoreducetheseverity
ofnicotinewithdrawal
symptoms.

13. 13BALFOUR DJ ET AL.PHARMACOLTHER1996
PHARMACOKINETICS
NICOTINE REPLACEMENT THERAPY
•Max Plasma
Concentration :
oGum: after 30 minutes
oPatch : after 9 hours
•Half life: 2-3 hours
•Metabolized: liver, lung and
kidney
•10-15% excreted unchanged
in urine
IBM MICROMEDEX DRUG REF.

14. 14
1. CPG TREATMENT OF TOBACCO USE DISORDER 2016
2. ZWARN,ETAL 2011
3, PACKAGE INSERT OF NICOTINE GUM & NICOTINE PATCH(NICORETTE ®)
SAFETY
NICOTINE REPLACEMENT THERAPY
•NRTissafetouseinpatientswithstablecardiovasculardisease
2
andisnotan
independentriskfactorforacutemyocardialevents
1
•Butitshouldbeusedwithcautionamongcertaincardiovascularpatientgroup:immediatepost
MI(within2weeks),seriousarrhythmias,unstableanginapectoris,recentcerebrovascular
events,angioplasty.
1,3
•Precaution–uncontrolledHPT,severe/moderatehepaticimpairment,severerenal
impairment,uncontrolledhyperthyroidism
•Contraindication:Hypersensitivitytonicotineoranyexcipientsinthenicotinegum/patch
3
•AllNRTmedicationsareFDApregnancyClassDagents.UseofNRTshouldbeconsidered
onlyitspotentialbenefitsoutweighstherisk.
1,3
•Similarfactorsshouldbeconsideredinlactatingwomen.
1,3

15. 15STEAD LF ET AL 2008
EFFICACY
NICOTINE REPLACEMENT THERAPY
•111 trials with over 40,000 participants.
•Risk ratio (RR) of abstinence for any form of NRT relative to control was 1.58 (95% CI: 1.50
to 1.66).
•Pooled RR for each type:
o1.43 (95% CI: 1.33 to 1.53, 53 trials) for gum
o1.66 (95% CI: 1.53 to 1.81, 41 trials) for patch
o1.90 (95% CI: 1.36 to 2.67, 4 trials) for inhaler
o2.00 (95% CI: 1.63 to 2.45, 6 trials) for lozenges
•Sufficient dose to maximize the
chances of success
•Study show that higher degree of
NRT is associated with greater
quit rate.

16. 16PACKAGE INSERT NICOTINE GUM & PATCH (NICORETTE ®)
OVERDOSE
NICOTINE REPLACEMENT THERAPY
•ExcessiveusenicotinefromeitherNRTand/orsmoking
•ORifmanypatchesusedsimultaneously
•ORuserhasverylownicotinedependence
•Symptoms:nausea,salivation,abdominalpain,diarrhoea,sweating,headache,dizziness,
disturbedhearingandmarkedweakness
•Worsen:hypotension,weakandirregularpulse,breathingdifficulties,circulatory
collapseandgeneralconvulsion
•Management:stopadministration,removepatchandrinseapplicationsitewith
water,ifexcessiveswallow–activatedcharcoal,treatsymptomatically

17. 17
NICOTINE GUM
•2mg
•4mg

18. 18
1. CPG TREATMENT OF TOBACCO USE DISORDER 2016
2.PACKAGE INSERT NICOTINE GUM (NICORETTE ®)
NICOTINE GUM 2MG @ 4MG
Dosage For monotherapy:
⮚Use at least one piece every 1 to 2 hours (Max 24 gum/day)
1,2
⮚Gradual tapering then stop when the dose is reduced to 1-2 gum/day
2
⮚Recommend use for at least 3 months
1,2
For combination therapy:
⮚Use 1 piece of gum when needed (referring to urge to smoke)
Which dose to
use?
⮚2mg gum (Low dependence)
✔less than 20 cigarettes per day
1
✔TTFC > 30 minutes
1,2
⮚4mg gum (High dependence)
✔20 or more cigarettes per day
1
✔TTFC < 30 minutes
1,2
Side Effects Mouth soreness, hiccups, dyspepsia, jaw ache
1
(Generally mild and transient and often can be alleviated by correcting the patient’s chewing technique)
1
Additional
precaution
Active duodenal and gastric ulcers, inflammation of the stomach and inflammation of the esophagus
2

19. 19
FACTORS TO
CONSIDER
NICOTINE
GUM
•Usingdentures.
•Frequentconsumptionofacidicdrinks/food.
(reduceamountavailableforabsorption)
•Habitualsmoker.(aftermeal,during“big
business”,etc.)andtocontrolthebreak
throughcraving.
•Highdependence:4mg;lowdependence:2mg
(adolescents)
•Useenoughofitforatleast3months.

20. When you get urge
to light up or as
scheduled
1
chew slowly until a “peppery”
or “flavoured” taste emerges
(about 10 chews)
2
Park gum
between gum
and cheek
3
Wait few minutes,
nicotine is being
released…
4
Switch to other side
and repeat the whole
process
5
20
After 30 minutes…
safety discard it
6
CHEWING TECHNIQUE

21. 21
COUNSELING
POINTS
NICOTINE GUM
1.Chew slowly so that the amount of nicotine release from the gum
can be absorbed. Chew too fast will increase saliva production which
cause most of the nicotine being swallowed instead of absorb
through buccal mucosa. Swallowing saliva containing nicotine will
cause side effects such as nausea, vomiting, bloating, stomach
discomfort, etc.
2.Parkto facilitate the absorption of nicotine through buccal mucosa.
3.Should change side of parking the gum because if it is keeping at
one same location too long may cause ulceration.
4.Advice patients to drink more water after the chewing the gum to
prevent ulceration (Note: NOT DURING chewing the gum or having
the gum in the mouth).
5.Acidic drinks will reduce the absorption of nicotine through buccal
mucosa. (If there is strong urge to smoke, patients insist of having
the acidic drink, we will still advice the patient to take the gum.
However, we should inform the patient that the amount of nicotine
being absorb will be less and thus will not be so effective).

22. 22
COUNSELING
POINTS
NICOTINE GUM
EXTRACOUNSELINGPOINTS:
•ChewitintheRIGHTWAY(itsnotlikeregularchewinggum)
•ChewONEgumatatime
•ChewSLOWLYabout10times,untilyoutastethe
peppery/mintytaste.(WHYslowly?)
•ThenPARKthenicotinegumbetweengumandcheek.
(WHY?)
•Whenthepeppery/mintytasteisover,chewthegumagain
SLOWLYandparkattheOTHERSIDEofthecheek.(WHY?)
•Discardthegumproperlyafter30MINUTES.
•DrinkalotofwaterAFTERchewingthegum(WHY?)
•Donoteatordrinkacidicbeverages15minbeforechewing
thenicotinegum.(BUTiftheurgetosmokeisstrong…)

23. REMEMBER TO EXPLAIN WHY
WHEN YOU ASK A PATIENT TO FOLLOW YOUR
INSTRUCTION…
23
So that he/she will be more compliance as well as realise
whether he/she is chewing correctly.

24. 24
USING
ENOUGH !!
NICOTINE GUM
•1030smokerwhoquitforatleast2weeksina
trialofnicotinelozenges
•28-daycontinuousabstinenceat6-week
follow-upwaspositivelycorrelatedwith
increasedNRTuse
•EachoneadditionalpieceofNRTused
increasetheoddsofquittingby10%
•Similareffectscanbeexpectedwithnicotine
gum
SHIFFMAN S. ADDICTION 2007

25. 25
NICOTINE
PATCH
1.In MOH Drug
Formulary:
•25mg/16hrs
•15mg/16hrs
•10mg/16hrs
2.Others in market:
•21mg/24hrs
•14mg/24hrs
•7mg/24hrs

26. 26
1. CPG TREATMENT OF TOBACCO USE DISORDER 2016
2.PACKAGE INSERT NICOTINE PATCH (NICORETTE ®)
NICOTINE PATCH
25MG @ 15MG @ 10MG/ 16 HOURS
Dosage •Recommend use for at least 3 months
2
•Taper down as per manufacturer’s recommendation.
2
Side Effectslocal skin reaction (50%), insomnia, vivid dreams, headache, dizziness, nausea & vomiting
1,2
Additional
Precaution
Chronic generalized dermatological disorders such as psoriasis, chronic dermatitis or
urticaria
2
*patch should be removed prior to MRI procedures to prevent risk of burns
2
8 WEEKS 2 WEEKS 2 WEEKS
25 MG PATCH 15MG PATCH 10 MG PATCH
>15
cig/day
8 WEEKS 4 WEEKS
15 MG PATCH 10MG PATCH
<15
cig/day

27. 27
FACTORS TO
CONSIDER
NICOTINE
PATCH
•Hairy?
•Sensitiveskinandskindiseasenotsuitable.
•Natureofthepatient’swork.Alwaysunderthe
sun,sweatalot,suitable?
•Hand-mouthhabit,suitable?

28. Fold and discard it
safely.
Remove seal at the
back of the patch
28
HOW TO USE THE NICOTINE PATCH?
Peel of the patch
Put the patch on
your arm or hip
(non-hairy area) &
seal it tightly
Leave it for about 16
hours (during working
hours)
Next day, put a new
patch on the different
side
1
4
32
5

29. 29
COUNSELING
POINTS
NICOTINE GUM
•PutNEWPATCHatthestartofeachday.Night?(How
todecide?)
•Removetheseal.(How?)
•PutthepatchonDRY,CLEAN&HAIRLESSpartofbody
(upperarmorsideoftorso)
•MakesurethepatchisSEALTIGHTLY,especiallyatthe
sides.(WHY?)
•Peeloffthepatchafter16hoursorfewhoursBEFORE
SLEEP.(WHY?)
•FOLDthepatchbeforediscard.
•Rotatingthesite(AVOIDusingtheSAMESITEforabout
5-7days)toreducelocalskinirritation.

30. 30
COUNSELING
POINTS
NICOTINE
PATCH
•Newpatcheachmorning/night.(Howtodecide?)
oIfTTFCislessthan30min,patchatnight.(to
counselpatchRIGHTbeforesleep,toavoid
insomnia)
oIfTTFCmorethan30min,patchinthemorning.
•Makesurethepatchissealtightly,especiallyatthe
sides.(WHY?)
oNobubblesorairtrapinthepatch,itwillstayon
theskinforalongtime.
oIfthepatchissealtightly,90%ofthenicotinewill
beabsorbedthroughtheskinbuttherestwill
evaporateandlostinair.
•Peeloffthepatchafter16hoursorfewhoursBEFORE
SLEEPtoavoidsleepdisturbance.

31. PUT A
TITLE??
31CPG TREATMENT OF TOBACCO USE DISORDER 2016
✔For smoker with TTFC < 30 min, put patch immediately before sleeping, so that plasma
nicotine level is highest upon waking up 6 to 8 hours post application of patch.
New
patch
Patch
applied
Patch
removed
Morning 6am 12pm 4pm 8pm 12am 4am 8am
Night10pm 4am 8am 12pm 4pm 8pm 12am
Peak

32. 32
HIGHER DOSE
PATCHES
NICOTINE
PATCH
•Sevenstudiescomparedhigherdosepatches
(e.g.44mg/24hours)withstandarddoses
(21mg/24hours)
•Overalltherewasasmallincreaseinlong-
termquitrates(RR=1.15,95%CI:1.01-1.30)
STEAD LF ET AL 2008

33. 33SCHNEIDER AT AL. NTR 2008
CHOOSING AN NRT PRODUCT BASED ON SAMPLING
•Explanationof the different products usually adequate
•However one study found that NRT preferences based on explanations
changed after sampling
•NRT sampling may lead to better choice and treatment compliance

34. 34SHIFFMAN ET AL 2006
CONTINUING NRT AFTER A LAPSE
•MostpeoplestopusingNRTwhentheylapse.
•WarninglabelsalsoadviseagainstusingNRTwhilesmoking.
•HowevercontinuingtouseNRTpatchmightreducetheprogressionto
relapse
oE.g.astudyofusingpatchshoweda5-foldreductionintheriskoffull
relapseinthosewhohadlapsed.

35. 35MOORE D ET AL 2009
NRT ASSISTED REDUCTION IN PEOPLE WHO
DON’T WANT TO QUIT ABRUPTLY
•SystematicreviewofsevenRCTsinvolving2767smokersnotwillingorabletostop
abruptly
•NRT-assistedreductionresultsinincreasedquittingandreductioncomparedto
placebo
Outcomes Event Rates
Smoking abstinence for 6 months 6.8% vs. 3.3%
Sustained smoking reduction 6.1% vs. 1.6%

36. 36HAJEK P ET AL 2007
LONGER-TERMUSE OF NRT
•SomepeoplerequireNRTforlongerthan12weeks.
•<10%ofpatientsonoralNRTand<15%onnasalsprayuseNRT
for1year.
•Thechancesoflong-termusearerelatedtospeedofnicotineabsorption.
•Long-termusersaremostlysmokerswhosechanceofsuccesswouldbe
otherwisesmall.

37. 37
CONTENTS
1. MEDICINE FOR SMOKING CESSATION
2. WHICH ONE TO USE?
3. NICOTINE REPLACEMENT THERAPY
4. NON-NICOTINE BASED PHARMACOTHERAPY
5. COMBINATION THERAPY
6. SMOKING AND DRUG INTERACTION

38. 38
VARENICLINE
(CHAMPIX
®
)
1.STARTER PACK
•Varenicline
0.5mg (11 tabs &
1mg (14 tabs)
2.CONTINUATION
PACK
•Varenicline 1mg
(28 tabs)
Starter PackContinuation Pack

39. 39
https://www.youtube.com/watch?v=abnymwz5ook
MECHANISM OF ACTION
VARENICLINE (CHAMPIX®)
A highly selective α4β2 receptor partial agonist
Agonist effect Antagonist effect
Ease craving & withdrawal symptoms Reducing the satisfaction / reward of continued
smoking
►Was approved by FDA for treatment of tobacco dependence in 2006
Lesser amount of
dopamine
release
Prevent
nicotine
binding

40. 40
PHARMACOKINETIC
VARENICLINE
(CHAMPIX®)
Varenicline Summary Of Product Characteristics. 2006
•Half-life~24hours
•Cmaxwithin3to4hours
•Steadystatereachedwithin4days
•Oralbioavailabilityunaffectedbyfood
•92%ofdrugisexcretedunchangedinthe
urine–adjustdoseinrenalimpairment
(Clcr<30ml/min)
•NoinhibitionofcytochromeP450enzymes-
noclinicallymeaningfuldruginteractions
identified
•Nodoserestrictionsinpatientswithhepatic
insufficiency

41. 41
1. CPG Treatment Of Tobacco Use Disorder 2016
2.Package Insert Varenicline (Champix®)
DOSAGE
VARENICLINE (CHAMPIX®)
DOSAGE
DAY 1-3 0.5 MG OD
DAY 4-7 0.5MG BD
WEEK 2-12 1MG BD
•Dose adjustment for patient with renal impairment (refer slide safety)
•For patients who cannot tolerate adverse effects –0.5mg BD
Patient to quit smoking on Day 8 -14
DURATION OF TREATMENT : 12 WEEKS (MAX 24 WEEKS)
SIDE EFFECTS
nausea (30%), insomnia, (14%), abnormal dreams (13%), headache (13%), constipation (9%), gas (6%) and vomiting
(5%) , trouble sleeping, abnormal/vivid/strange dreams, abdominal pain, flatulence,mayimpair the ability to drive or
operate heavy machinery.
STARTER PACK

42. 42
COUNSELING
POINTS
VARENICLINE
(CHAMPIX®)
•Take at the same time everyday.
•If missed dose, take as soon as pateintremember. If it is
within 3-4 hours before the next dose, do not take the
tablet that have missed.
•Take with food (non-oily food) and swallowed whole
with a full glass of waterto minimize nausea.
•Take second pill at supper time or after dinner instead
of bedtime if patient experience insomnia.

43. 43
EFFICACY
VARENICLINE
(CHAMPIX®)
Cahill K et al 2016
Cochrane review
✔11 trials, 6892 of whom used varenicline.
✔Varenicline at standard dose increased the chances of
successful long-term smoking cessation between 2 and
3x compared with pharmacologically unassisted quit
attempts.

44. 44
SAFETY
VARENICLINE
(CHAMPIX®)
CPG Treatment of Tobacco Use Disorder 2016
Precaution & contraindication
1.RenalImpairment
i.Forpatientswithmoderaterenalimpairmentwhoexperience
adverseeventsthatarenottolerable:1mgoncedaily.
ii.Forpatientswithsevererenalimpairment(estimatedcreatinine
clearance<30mL/min):Dosingshouldbeginat0.5mgoncedailyfor
thefirst3daysthenincreasedto1mgoncedaily.
iii.NotrecommendedforESRDpatient
2.Pregnancy&breastfeeding
-FDApregnancyClassCagent
-Shouldnotbeusedduringpregnancy&breastfeeding
3.Adolescents
-Notrecommendedforuseinpatientsunder18yearsofage.

45. 45
SAFETY
VARENICLINE
(CHAMPIX®)
Anthenelli RM et al 2016
Neuropsychiatric Adverse Effects
Updates: EAGLES Study 2016
✔Over 12 weeks of treatment with 12-week non-treatment follow
up, in 8,144 smokers with or without a diagnosis of psychiatric
disorders, EAGLES has shown that CHAMPIX has:
NOSIGNIFICANTLYINCREASEDNEUROPSYCHIATRIC(NPS)
SAFETYRISKvs.placebo,insmokerswithorwithoutahistoryof
psychiatricdisorders
✔Food and Drug Administration approved the removal of the
warning label from the vareniclinepackaging on December 16,
2016.

46. 46
SAFETY
VARENICLINE
(CHAMPIX®)
Anthenelli RM et al 2016
EVALUATINGADVERSE EVENTS IN A
GLOBAL SMOKING CESSATION STUDYEAGLES
FINDINGS:
⮚More neuropsychiatric adverse
events were reported in
psychiatric cohort
⮚SIMILAR ACROSS TREATMENT
⮚Use of vareniclinewere NOT
associated with significantly
increased risk of NPS AEs

47. 47
SAFETY
VARENICLINE
(CHAMPIX®)
CPG Treatment of Tobacco Use Disorder 2016
SMOKINGCESSATIONANDTHEPSYCHE
•Depressivesymptomsandonrareoccasions–suicidal
ideationshavebeenreported.
•Smokingcessation,withorwithouttreatment,is
associatedwithnicotinewithdrawalsymptomsandhas
alsobeenassociatedwiththeexacerbationof
underlyingpsychiatricillness.
•Healthcareprovidersshouldbeawareofthepossible
emergenceofsuchbehavioralchangesinpersons
attemptingsmokingcessationandrefer/advisepatients
appropriately.

48. 48
CONTENTS
1. MEDICINE FOR SMOKING CESSATION
2. WHICH ONE TO USE?
3. NICOTINE REPLACEMENT THERAPY
4. NON-NICOTINE BASED PHARMACOTHERAPY
5. COMBINATION THERAPY
6. SMOKING AND DRUG INTERACTION

49. 49TEACH A COURSE
COMBINATION THERAPY
Nicotine Gum +
Nicotine Patch
Varenicline+ NRT
1 2

50. 50Stead LF Et Al 2008
COMBINATION THERAPY
1. NICOTINE PATCH + NICOTINE GUM
•CombiningtwoformsofNRT(Patch+gum/lozenge)hasbeenshowntobemore
efficaciousthanasingleformofnicotinereplacement.
•6trialscomparingcombinationwithsingleNRTshowsadvantageofcombinationuse
RR=1.35(95%CI:1.11-1.63).
•IncidenceofadverseeventswithcombinationNRTisnotsignificantlygreater
thanthatwithsingleNRTuse
Patch-provides
background craving
relief
Intermittent dosing product -for
control of ‘breakthrough
craving’+

51. 51
COMBINATION
THERAPY
1. NICOTINE
PATCH +
NICOTINE
GUM

52. 52
COMBINATION
THERAPY
1. NICOTINE
PATCH +
NICOTINE
GUM

53. 53
COMBINATION
THERAPY
1. NICOTINE
PATCH +
NICOTINE
GUM

54. 54Bittoun et al 2009
COMBINATION THERAPY
2. VARENICLINE+ NRT

55. 55
CONTENTS
1. MEDICINE FOR SMOKING CESSATION
2. WHICH ONE TO USE?
3. NICOTINE REPLACEMENT THERAPY
4. NON-NICOTINE BASED PHARMACOTHERAPY
5. COMBINATION THERAPY
6. SMOKING AND DRUG INTERACTION

56. 56
PAHS & DRUG METABOLISM
•PolycyclicAromaticHydrocarbons(PAHs)intobaccosmokeisanpotentinducerof
HepaticcytochromeP-450(CYP)isoenzymes.
•ThreeinducibleCYP1familygenes(A1,A2andB1).
•HepaticCYP1A2isfunctionallymostimportantCYP1geneduetoalmostexclusiveliver
expression.
•Drugs(substrates)oftheisoenzyme(s)mayhave↑metabolism(↑clearance,↓half-life)in
smokers,
•Afterquitsmoking,clearanceofcertainmedicationswhicharemetabolizedviaCYP1A2
maybereduced.
•Thismayleadtoincreasedplasmalevelsofcertainmedications.
•Eg:clozapine,olanzapine,fluvoxamine,haloperidol,naratiptan(antimigraine),theophylline

57. 57Faber & Fuhr2004
HOW QUICKLY DOES THE INDUCTION OF CYP1A2
DISSIPATE UPON SMOKING CESSATION?
•In12subjectssmoked≥20cigs/d(range22.3–27.7cigs):
•Half-life(t1/2)ofCYP1A2activityaftersmokingcessation=38.6hours
Day post quit RR in CYP1A2 activity
1 12.3%
2 20.1%
3 25.0%
4 28.2%
7 (steady state) 36.1%

58. 58
SMOKING & DRUG
INTERACTION
PHARMACOKINETIC
INTERACTIONS

59. 59
SMOKING & DRUG
INTERACTION
PHARMACOKINETIC
INTERACTIONS

60. 60
SMOKING & DRUG
INTERACTION
PHARMACOKINETIC
INTERACTIONS

61. 61
SMOKING & DRUG
INTERACTION
PHARMACODYNAMIC
INTERACTIONS

62. 62
SMOKING & DRUG
INTERACTION
SUMMARY

63. PENGENALAN
Penggunaantembakau:Penyebabutama
kematianpramatangdankematianyang
bolehdicegahdiMalaysia.
Merokokmenyumbangkepada15%
daripadajumlahkemasukanpesakitke
hospitaldan35%daripadajumlah
keseluruhankematiandihospital
1
.
Anggaran20,000kematiansetahundi
kalanganrakyatMalaysiadandijangka
akanmeningkatkepada30,000
sekiranyatiadaperubahandalamtrend
tabiatmerokok
1
.
Merokokmemberikesanberbahaya
kepadakesihatanfizikaldan
menyebabkankesanketagihannikotin
yangberpanjangankepadaperokok.
63
1.Institute For Public Health. National Health And Morbidity Survey 2015 –Report On Smoking Status Among Malaysian Adults. Kuala Lumpur; 2015.
2.Tobacco And Electronic Cigarette Survey Among Malaysian Adolescent 2016 –TECMA
TobaccoAndElectronicCigaretteSurvey
AmongMalaysianAdolescent2016:
78.7%remajaberumur10-19tahun
pernahhisaprokokkalipertamasebelum
umur14tahun
2
.
28.5%daripadaremajayangmerokok
telahmenunjukkanketagihannikotin
tahaprendah.
Peratus
Perokok
Semasa
(Current
smoker)
Global Adult
Tobacco
Survey
(GATS) 2011
Kajian
Morbiditi&
Kesihatan
Kebangsaan
Tahun 2015
Keseluruhan 23.1% 22.8%
Lelaki 43.9% 43.0%
Perempuan 1.0% 1.4%
Penemuanbaru&perubahandalam
rawatanberhentimerokok,dan
kemunculanproduknikotinyangbaru
sepertirokokeletronik(e-cigarette)
“

64. OBJEKTIF
64
•MeningkatkankualitiperkhidmatanBerhentiMerokokdi
semuafasilitiKementerianKesihatanMalaysiamelalui
penglibatanpegawaifarmasisecaraaktifdandinamik.
1
•MenyediakanrujukanbagipelaksanaanFarmakoterapi
BerhentiMerokokyangdijalankanolehpegawaifarmasi.
2
•MenyeragamkanperkhidmatanFarmakoterapiBerhenti
Merokokyangdijalankanolehpegawaifarmasidifasiliti
kesihatanKementerianKesihatanMalaysia.
3

65. 65
•PelaksanaanFBMdiklinikkesihatanmestiselarasdenganGarisPanduanPerkhidmatanBerhenti
MerokokdiKlinikKesihatan(Julai2011)olehBahagianPembangunanKesihatanKeluarga,KKM
sementarapelaksanaandiperingkathospitalperluselaridenganManualLatihanKebangsaan
dalammembantuperokokberhentimerokokpadatahun2005olehBahagianPendidikan
Kesihatan,KKM.
GARISPANDUAN
•PegawaifarmasiyangterlatihdalammengendalikanFBMsertatelahlulusCertifiedSmoking
CessationServiceProvider(CSCSP)sahajabolehmelaksanakanFBM.
CSCSP
•PengurusanrawatanbagipesakitFBMdijalankanmengikutmodulfarmakoterapiberhenti
merokokyangdisyorkandalamgarispanduanini.PanduanKaunselingFarmakoterapiBerhenti
MerokokdisertakansebagairujukandalammelaksanakanperkhidmatanFBM(rujukLampiran4).
MODUL FBM
•PerlaksanaanFBMperludidokumentasikandandilaporkankeProgramPerkhidmatanFarmasi
setiap6bulanataudiperlukanbagitujuanpemantauan.
DOKUMENTASI & PELAPORAN
FBM:
Perkhidmatanberhentimerokokmelibatkan2jenisrawataniaitufarmakologidannonfarmakologi.Rawatan
farmakologimelibatkanpenggunaanubatbagirawatanketagihannikotindandikenalisebagaifarmakoterapiberhenti
merokok(FBM).Manakalabagirawatannon-farmakologi,pesakitdiberikaunselingmodifikasitingkahlaku
(behaviouraltherapy)tanpapenggunaanubat-ubatan.

66. 66TEACH A COURSE
CONCLUSION
Smokingcessationtreatmentshouldbeindividualized.
Optimizingtreatmentwithapprovedmedications(e.g
NRT,varenicline)+behaviouralinterventionshould
improveclinical,humanisticandeconomicoutcomes.

67. REFERENCES
67
1.KateCahill*,SarahStevens,RafaelPerera,StevensS,PereraR,
LancasterT.Pharmacologicalinterventionsforsmokingcessation:an
overviewandnetworkmeta-analysis.CochraneDatabaseof
SystematicReviews2013,Issue5.Art.
2.U.S.DepartmentofHealthandHumanServices.PublicHealth
Service.May2008
3.BalfourDJetal.Pharmacologyofnicotineanditstherapeuticusein
smokingcessationandneurodegenerativedisorders.PharmacolTher
1996;72:51-81
4.IBMMicromedexDrugRef.
5.CPGTreatmentofTobaccoUseDisorder2016
6.ZwarN,etal.TheRoyalAustralianCollegeofGeneralPractitioners,
2011
7.PackageInsertNicotineGum&NicotinePatch(Nicorette®)
8.SteadLF,PereraR,BullenC,MantD,LancasterT.Nicotine
replacementtherapyforsmokingcessationCochraneDatabaseSyst
Rev.2008Jan23;(1):CD000146.
9.ShiffmanS.Useofmorenicotinelozengesleadstobettersuccessin
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10.Schneideratal.Preferencesamongfivenicotinetreatmentsbasedon
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68. THANK YOU!