Tools for Practice Outils pour la pratique


#27 Pharmacotherapy for Smoking: Which work and what to consider (Part II)?


CLINICAL QUESTION
QUESTION CLINIQUE
In patients ready to make a smoking cessation attempt, how effective are registered first-line medications and what are the potential concerns?


BOTTOM LINE
RÉSULTAT FINAL
Bupropion, nortriptyline and varenicline are all effective in smoking cessation, with varenicline more-so. Adverse events vary and may in part relate to quitting smoking, and require monitoring.



CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session



EVIDENCE
DONNÉES PROBANTES
See Part 1 for nicotine replacement therapy (NRT).
  • Antidepressants: Cochrane review of bupropion 65 and nortriptyline 10 randomized controlled trials (RCTs).1
    • Risk Ratio (RR) for cessation over placebo,
      • Bupropion (at 6-12 months): 1.62 (1.49-1.76)
      • Nortriptyline (at 6 months): 2.03 (1.48-2.78)
    • Serious adverse events:
      • Bupropion: Seizure (about 1/1000) and suicidal thoughts/behavior (association unclear) are rare.
    • SSRI (6 RCTs) and venlafaxine (1 RCTs): not effective.
  • Varenicline:
    • Cochrane review2 of 39 RCTs: RR for cessation at 6-12 months over placebo= 2.24 (2.06-2.43)
      • RR over bupropion= 1.39 (1.25-1.54)
      • RR over NRT = 1.25 (1.14-1.37)
    • Serious Adverse Events: RR 1.25 (1.05-1.49)
    • Neuropsychiatric safety: Early studies2,3 suggested possible increase in depression, irritability, and suicidal thoughts/attempts, however:
      • Systematic review4 of 39 RCTs: No increase versus placebo
      • RCT5 0f 8,144 (50% with psychiatric disorder): No difference versus placebo, NRT or bupropion
      • Cohort6 of ~120,000 patients: No difference between varenicline, bupropion or NRT.
    • Cardiovascular events: No increase (see updated Tools for Practice #71).
  • Assuming 10% placebo cessation rates (mean across studies), number needed to treat: Varenicline 8, Nortriptyline 10 and Buproprion 10.
Context:
  • Risk of bias in varenicline evidence:
    • Superiority of varenicline > buproprion is at risk of funding bias
    • Previously noted publication bias: In 2011, 75% of varenicline trials were unpublished.7
  • Health Canada recommends “thorough consideration” of NRT before varenicline or bupropion.8
  • Dosing:
    • Lower doses are effective:
      • Bupropion 150 mg is equivalent to 300 mg1,9
      • Varenicline 0.5 mg BID may be slightly less effective than 1 mg BID (with fewer adverse events)2,10
    • Nortriptyline: Can start at 25 mg qhs and increase by 25 mg every 3-4 days, if needed, to a maximum of 75-100 mg. Encouraged quit date 10 days in (or so) and continue for 10-12 weeks.


Latest Tools for Practice
Derniers outils pour la pratique

#365 Shrooms for Glooms: Evidence for psilocybin for depression

What are the benefits and harms of psilocybin for treatment-resistant/recurrent depression?
Read Lire 0.25 credits available Crédits disponibles

#364 Facing the Evidence in Acne, Part II: Oral Antibiotics

How effective are oral antibiotics in treating acne of at least mild-moderate severity?
Read Lire 0.25 credits available Crédits disponibles

#363 Making a difference in indifference? Medications for apathy in dementia

In patients with dementia, how safe and effective are stimulants, antidepressants, and antipsychotics for treating apathy?
Read Lire 0.25 credits available Crédits disponibles

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session


Author(s)
Auteur(s)
  • Charl Els MBChB FCPsych (Psychiatry)
  • G. Michael Allan MD CCFP

1. Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Cochrane Database System Rev. 2014;1:CD000031.

2. Cahill K, Lindson-Hawley N, Thomas KH, Fanshawe TR, Lancaster T. Cochrane Database System Rev. 2016;5:CD006103.

3. Gunnell D, Irvine D, Wise L, et al. BMJ. 2009; 339:b3805.

4. Thomas KH, Martin RM, Knipe DW, Higgins JPT, Gunnell D. BMJ. 2015;350:h1109.

5. Anthenelli RM, Benowitz NL, West R, et al. Lancet. 2016;387:2507-20.

6. Thomas KH, Martin RM, Davies NM, et al. BMJ. 2013; 347:f5704.

7. Brophy JM. Ann Intern Med. 2011 Oct 18; 155:JC4-5.

8. Health Canada. http://healthycanadians.gc.ca/recall-alert-rappel-avis/hcsc/2013/33621a-eng.php. Accessed Nov. 7, 2013.

9. Hurt RD, Sachs DP, Glover ED, et al. New Engl J Med. 1997; 337:1195-202.

10. Fouz-Roson N, Montemayor-Rubio T, Almadana-Pacheco, et al. Addiction. 2017;112:1610-9.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.