The
faster-acting nicotine replacement therapies (NRTs) include nicotine mouth
spray, nicotine inhalers, nicotine nasal spray, nicotine nasal spray and
nicotine sublingual tablet. Here is a brief overview of each.
Nicotine mouth spray: It delivers
1 mg nicotine per spray. Used as 1 to 2 sprays when craving occurs, up to
4 sprays per hour. Side effects occurring frequently with the oral spray
include hiccups (occurring in more than 55% of those treated in one trial,
throat irritation, and nausea (Eur Respir J. 2012;40:548).
Nicotine inhalers: They release
nicotine vapor (not smoke). The ad lib use of the nicotine inhaler produces
plasma nicotine levels that are roughly one-third of those that occur with
cigarette smoking. Use 6 to 16 cartridges per day for the first 6 to 12 weeks
and gradually reduce dose over the next 6 to 12 weeks. Commonly occurring side
effects include localized irritation of the mouth or throat, particularly
during the early stages of use. Because inhaled nicotine may cause
bronchospasm, it may be less appropriate for smokers with a history of severe
airway reactivity.
Nicotine nasal spray: It delivers an
aqueous solution of nicotine to the nasal mucosa. The peak nicotine level
occurs at 10 minutes. Dose is 1 or 2 sprays per hour for three months. The
maximum dose is 10 sprays per hour, not to exceed 80 total sprays per day. Side
effects include nasal and throat irritation, rhinitis, sneezing, and tearing.
Nasal irritation is extremely common, occurring in 94% of patients during the
first two days of use and continuing in 81% of patients after three weeks of
therapy (Medical Economics, Montvale, NJ 1998).
Nicotine sublingual tablet: It
is administered as 2 mg tablet sublingually (over 30 minutes) every one
to two hours. Patients who are heavily nicotine-addicted can use 2 tablets
sublingually (4 mg total) for each dose (Nicotine Tob Res. 2002;4:441).
Side effects occurring commonly include sore mouth or throat and dryness or
burning in the mouth.
Cardiac safety of NRTs
·
Nicotine replacement is delivered by nicotine
polacrilex gum, nicotine lozenges, nicotine nasal spray or transdermal nicotine
·
The Lung Health Study cohort of 5887 middle-aged
smokers with chronic obstructive pulmonary disease who were followed for five
years compared smokers with those who quit with or without nicotine gum. There
was no increase in hospital admission for cardiovascular events with nicotine gum
treatment, regardless of the dose used. Participants who quit smoking
successfully and used nicotine gum had a lower hospital admission rate for
cardiovascular disease than subjects who did not quit smoking, regardless of
whether or not they used the gum (fda.gov/Drugs/DrugSafety/ucm259161.htm).
·
The results of two other controlled trials of nicotine
replacement and one population-based case-control study of patients with cardiovascular
disease also provided no evidence for an increase in coronary events with
replacement therapy (CMAJ. 2011;183:1359).
·
A randomized trial of 584 patients (almost all men)
with at least one diagnosis of cardiovascular disease found no difference in
the incidence of primary cardiovascular end points (death, myocardial
infarction, cardiac arrest, and admission to the hospital for cardiovascular
disease) at 14 weeks between the nicotine and placebo groups (5.4 vs 7.9
percent with placebo) (accessdata.fda.gov/drugsatfda_docs/label/2018/021928s045_046lbl.pdf). Overall,
the evidence suggests that chemicals other than nicotine are responsible for
the elevated risks of myocardial infarction and stroke in smokers. The risks of
nicotine medication in patients with cardiovascular disease, if any, are much
lower than those of smoking, and the benefits of nicotine medication far
outweigh the risks of continued smoking in such patients.
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of
Medical Associations in Asia and Oceania
(CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of
India
Past National President
IMA
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