4.10.2 Nicotine dependence

Bupropion

Modified-release tablets 150mg (£41.76 = 60 tablets)

Indications

An aid to smoking cessation in combination with motivational support in nicotine-dependent patients

Dose

Start 1–2 weeks before target stop date, initially 150mg daily for 6 days then 150mg twice daily; period of treatment 7–9 weeks; discontinue if abstinence not achieved at 7 weeks; consider maximum 150mg daily in patients with risk factors for seizures and the elderly

Notes

Medicine Supply Notification 01 December 2022 (MSN/2022/100):
1. bupropion (Zyban) 150mg modified-release tablets will be out of stock until further notice
2. no new patients should be initiated on bupropion 150mg modified-release tablets
3. assess the need to taper off bupropion to reduce the risk of discontinuation effects, if patients have sufficient supply to do so
4. various nicotine replacement therapies are available
5. specialist advice is required on alternative products where bupropion is used off-label.
Bupropion is licensed as an adjunct to smoking cessation in combination with motivational support in adults.
Bupropion has been associated with seizures (see note 5 below), which occur in around 1 in 1,000 patients treated (0.1%).
Insomnia is a very common adverse event which can be reduced by avoiding bedtime doses of bupropion (provided there is at least 8 hours between doses).
Patients should exercise caution before driving until they know whether bupropion affects their ability to drive.
Bupropion is contra-indicated in patients with a history of seizures or of eating disorders, a history of bipolar disorder, a CNS tumour, or who are experiencing acute symptoms of alcohol or benzodiazepine withdrawal. Bupropion should not be prescribed to patients with other risk factors for seizures unless the potential benefit of smoking cessation clearly outweighs the risk. Factors that increase the risk of seizures include concomitant administration of drugs that can lower the seizure threshold (e.g. antidepressants, antimalarials (such as mefloquine and chloroquine), antipsychotics, quinolones, sedating antihistamines, systemic corticosteroids, theophylline, and tramadol), alcohol abuse, history of head trauma, diabetes, and use of stimulants and anorectics
MHRA Drug Safety Update (November 2020): Bupropion (Zyban): risk of serotonin syndrome with use with other serotonergic drugs
- cases of serotonin syndrome have been reported in association with bupropion and co-administration with serotonergic drugs, for example
  - selective serotonin reuptake inhibitors (SSRIs)
  - serotonin norepinephrine re-uptake inhibitors (SNRIs)
- if concomitant prescribing with other serotonergic drugs is clinically warranted:
  - do not exceed the recommended dose
  - remind patients of the milder symptoms of serotonin syndrome at initiation of treatment and at any change of dose and the importance of seeking medical advice if they occur
  - if serotonin syndrome is suspected, either decrease the dose of bupropion or withdraw therapy depending on the severity of the symptoms
- Advice to give to patients:
  - if you are told you may be at risk of serotonin syndrome, be aware of symptoms, including mild signs such as nausea, vomiting, and diarrhoea or increased heart rate and agitation (see Drug Safety Update for full list) and talk to your prescriber if you experience these
  - never exceed the prescribed dose of bupropion

Nicotine replacement therapy (NRT)

Referral to the Stop Smoking Service or 'in practice' smoking advice and support

Stop Smoking Service details can be found here:
- Torbay
- Plymouth

Nicorette®

Chewing gum 2mg, 4mg, 6mg (4mg = £22.07, 15 pieces daily for 14 days)
16 hour Invisipatch® 10mg, 15mg, 25mg (£22.86 = 14 days)
Inhalator 15mg cartridge (£74.18 = 14 days)
Cools lozenge 2mg, 4mg (£30.14 = 4mg x 14 days)
QuickMist oromucosal spray 1mg per dose (£16.18 = 150 doses)

Indications

Nicotine replacement as an aid to smoking cessation or reduction

Dose

Gum: chew one piece as needed; each piece should be chewed until the taste becomes strong and then rested between cheek and gum. Once the taste starts to fade, repeat the process. Each piece lasts approximately 30mins. Maximum dose 15 pieces per day
Patch: apply one each morning; remove after 16 hours. A new patch is applied to a different site the following morning.
Inhalator: Insert one cartridge into the device and inhale through the mouthpiece when the urge to smoke occurs. Patients should use no more than 6 x 15mg cartridges per day. A single 15mg cartridge lasts for approximately 40 minutes of intense use. One cartridge can be used for more than one period of craving
Lozenge: slowly allow dissolving in the mouth; periodically move the lozenge from one side of the mouth to the other. Lozenges last for 10–30 minutes, depending on their size. Maximum 15 lozenges daily
Oromucosal spray: use 1–2 sprays in the mouth when the urge to smoke occurs or to prevent cravings. Individuals should not exceed 2 sprays per episode (up to 4 sprays every hour), and a maximum of 64 sprays daily.

Nicotinell®

24 hour patch TTS 10 (7mg), TTS 20 (14mg), TTS 30 (21mg) (£19.94 = 14 days x 21mg)

Indications

Nicotine replacement as an aid to smoking cessation or reduction

Dose

Apply one patch each morning; remove after 24 hours. Remove and replace with a new patch applied to a different site the following morning.

Notes

Nicotinell® TTS 10 (7mg) patches are only indicated for the small proportion of clients who require a gradual step down process. Treatment should not be continued beyond 4 weeks.

NiQuitin®

Lozenge 2mg, 4mg (4mg = £21.58, 15 daily for 14 days)

Indications

Nicotine replacement as an aid to smoking cessation or reduction

Dose

Slowly allow dissolving in the mouth; periodically move the lozenge from one side of the mouth to the other. Lozenges last for 10–30 minutes, depending on their size. Maximum 15 lozenges daily

Notes

NiQuitin® lozenges are contraindicated for patients with phenylketonuria, they are sugar free, but do contain aspartame which metabolises to phenylalanine, which is of relevance for those with phenylketonuria.

Varenicline

Supply Disruption Alert 28 October 2021 (SDA/2021/006(U)): This supply disruption alert update supersedes the previous update issued on 24 June 2021 and advises on the following:
- There is no date for resupply of Champix (varenicline) or availability of varenicline products until further notice
- No new patients should be initiated on Champix (varenicline) products.
NICE TA123: Varenicline (Champix) is recommended within its licensed indications as an option for smokers who have expressed a desire to quit smoking (July 2007)
- Varenicline should normally be prescribed only as part of a programme of behavioural support.
Suicidal behaviour and varenicline, MHRA/CHM advice: Patients should be advised to discontinue treatment and seek prompt medical advice if they develop agitation, depressed mood, or suicidal thoughts. Patients with a history of psychiatric illness should be monitored closely while taking varenicline.

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