American Thoracic Society: New pharmacotherapy guidelines on smoking cessation

Organisation: Position: Deadline Date: Location:

An evidence-based guideline from the American Thoracic Society addresses several pharmacotherapy-initiation questions for treating tobacco use and dependence. The overall message is a recommendation in favour of varenicline over other forms of monotherapy, reports the American Pharmacists Association.

The guideline includes five strong recommendations and two conditional recommendations about pharmacotherapy for smoking cessation, says the report dated 25 September 2020.

In states where pharmacists can prescribe cessation medications, these recommendations can provide guidance for a ‘starting point’ in the discussion about medication options with patients, said Karen Hudmon, professor of pharmacy practice at Purdue University College of Pharmacy, whose primary clinical and research focus has been on tobacco cessation.

“Varenicline should be prescribed with confidence,” she said. “However, combination [nicotine replacement therapy] is a comparable alternative that was not addressed in the recommendations.”

Combination nicotine replacement therapy (NRT) involves the use of the nicotine patch plus a short-acting NRT agent. And compared to varenicline, it comes at a much lower financial cost to patients.

“I recommend either varenicline or combination NRT as a starting point for discussions about treatment options because these are associated with the highest quit rates,” she said. “Between these two approaches, it will usually be a matter of patient preference.”

Where prescriptive authority for cessation medications is not yet permitted, pharmacists can lean toward the OTC combination of the nicotine patch plus the nicotine gum and/or the nicotine lozenge. Pharmacists can also contact the patient’s primary care provider for varenicline or other prescription cessation agents, such as the nicotine inhaler or the nasal spray.

Hudmon was surprised to see that the expert panel’s recommendations advocated for initiating varenicline in patients who were not ready to quit, rather than waiting until patients are ready, and is sceptical about the practicality of the recommendation.

“It’s not clear whether patients will be interested in this approach, especially given the current cost of varenicline,” she said. Additionally, despite ample evidence supporting the efficacy of cessation medications, most patients attempt to quit without medication.

Hudmon found the (strong) recommendation for the use of varenicline versus the nicotine patch in patients with comorbid psychiatric conditions to be an important takeaway from the report.

“This guidance, which was based on data from two randomised trials, will hopefully be useful to alleviate clinicians’ discomfort with prescribing varenicline in these patient populations,” she said.

 

Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline

American Journal of Respiratory and Critical Care Medicine, Volume 202, Issue 2.

Authors

Frank T Leone *,  Yuqing Zhang *, Sarah Evers-Casey, A Eden Evins, Michelle N Eakin, Joelle Fathi, Kathleen Fennig, Patricia Folan, Panagis Galiatsatos, Hyma Gogineni, Stephen Kantrow, Hasmeena Kathuria, Thomas Lamphere,m Enid Neptune, Manuel C Pacheco, Smita Pakhale, David Prezant, David PL Sachs, Benjamin Toll, Dona Upson, Dan Xiao, Luciane Cruz-Lopes, Izabela Fulone, Rachael L Murray, Kelly K O’Brien, Sureka Pavalagantharajah, Stephanie Ross, Yuan Zhang, Meng Zhu and Harold J Farber.

Abstract

Current tobacco treatment guidelines have established the efficacy of available interventions, but they do not provide detailed guidance for common implementation questions frequently faced in the clinic. An evidence-based guideline was created that addresses several pharmacotherapy-initiation questions that routinely confront treatment teams.

Methods

Individuals with diverse expertise related to smoking cessation were empanelled to prioritise questions and outcomes important to clinicians. An evidence-synthesis team conducted systematic reviews, which informed recommendations to answer the questions.

The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used to rate the certainty in the estimated effects and the strength of recommendations.

Results

The guideline panel formulated five strong recommendations and two conditional recommendations regarding pharmacotherapy choices. Strong recommendations include using varenicline rather than a nicotine patch, using varenicline rather than bupropion, using varenicline rather than a nicotine patch in adults with a comorbid psychiatric condition, initiating varenicline in adults even if they are unready to quit, and using controller therapy for an extended treatment duration greater than 12 weeks.

Conditional recommendations include combining a nicotine patch with varenicline rather than using varenicline alone and using varenicline rather than electronic cigarettes.

Conclusions

Seven recommendations are provided, which represent simple practice changes that are likely to increase the effectiveness of tobacco-dependence pharmacotherapy.

 

Questions and Recommendations

Question 1: For Tobacco-Dependent Adults in Whom Treatment Is Being Initiated, Should Treatment Be Started with Varenicline or a Nicotine Patch?

Question 2: For Tobacco-Dependent Adults in Whom Treatment Is Being Initiated, Should Treatment Be Started with Varenicline or Bupropion?

Question 3: For Tobacco-Dependent Adults in Whom Treatment Is Being Initiated, Should Treatment Be Started with Varenicline plus Nicotine-Replacement Therapy or Varenicline Alone?

Question 4: For Tobacco-Dependent Adults in Whom Treatment Is Being Initiated, Should Treatment Be Started with Varenicline or an Electronic Cigarette?

Question 5: In Tobacco-Dependent Adults Who Are Not Ready to Discontinue Tobacco Use, Should Clinicians Begin Treatment with the Optimal Controller or Wait Until They Are Ready to Stop Tobacco Use?

Question 6: In Tobacco-Dependent Adults with Comorbid Psychiatric Conditions, Including Substance-Use Disorder, Depression, Anxiety, Schizophrenia, and/or Bipolar Disorder, for Whom Treatment Is Being Initiated, Should Clinicians Start with the Optimal Controller Identified for Patients without Psychiatric Conditions or Use a Nicotine Patch?

Question 7: In Tobacco-Dependent Adults for Whom Treatment Is Being Initiated with a Controller, Should They Be Treated with an Extended-Duration (>12 wk) or Standard-Duration (6–12 wk) Regimen?

Summary of Recommendations

  1. For tobacco-dependent adults in whom treatment is being initiated, we recommend varenicline over a nicotine patch (strong recommendation, moderate certainty in the estimated effects). Remarks: To promote adherence to pharmacologic therapy, providers should be prepared to counsel patients about the relative safety and efficacy of varenicline treatment compared with a nicotine patch.
  2. For tobacco-dependent adults in whom treatment is being initiated, we recommend varenicline over bupropion (strong recommendation, moderate certainty in the estimated effects).
  3. For tobacco-dependent adults in whom treatment is being initiated, we suggest varenicline plus a nicotine patch over varenicline alone (conditional recommendation, low certainty in the estimated effects).
  4. For tobacco-dependent adults in whom treatment is being initiated, we suggest varenicline over electronic cigarettes (conditional recommendation, very low certainty in the estimated effects). Remarks: The recommendation’s strength reflects very low certainty in the effects used to derive the recommendation. After our evidence synthesis, new evidence emerged regarding serious adverse effects of electronic cigarettes. If these serious adverse effects continue to be reported, the strength of the recommendation should be reevaluated. Note that this recommendation is intended for treatment of tobacco dependence under the supervision of a clinician; it should not be extrapolated to unsupervised treatment or recreational use.
  5. In tobacco-dependent adults who are not ready to discontinue tobacco use, we recommend that clinicians begin treatment with varenicline rather than waiting until patients are ready to stop tobacco use (strong recommendation, moderate certainty in the estimated effects).
  6. For tobacco-dependent adults with comorbid psychiatric conditions, including substance-use disorder, depression, anxiety, schizophrenia, and/or bipolar disorder, for whom treatment is being initiated, we recommend varenicline over a nicotine patch (strong recommendation, moderate certainty in the estimated effects).
  7. For tobacco-dependent adults for whom treatment is being initiated with a controller, we recommend using extended-duration (>12 wk) over standard-duration (6–12 wk) therapy (strong recommendation, moderate certainty in the estimated effects).

 

New guideline strongly recommends varenicline for smoking cessation

 

Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline

 


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